2027 CAHPS for MIPS Vendor Participation Form

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National Implementation of the Consumer Assessment of
Healthcare Providers and Systems (CAHPS) for the
Merit-based Incentive Payment System (MIPS) Survey
2027 CAHPS for MIPS Survey Vendor Participation Form
The following items are required for your organization to be a Centers for Medicare & Medicaid
Services (CMS) survey vendor of the CAHPS for MIPS Survey:
1. Meet all of the minimum survey vendor business requirements at the time of the submission
of this form.
2. Fill out the participation form below. Please note sections indicated with an asterisk (*) are
required.
Note: Organizations must also adhere to the Rules of Participation
If your organization is approved to be a survey vendor for the CAHPS for MIPS Survey, all staff
and all of your subcontractors must conduct all of your business activities in the United States.
All vendor applications and materials are due by April XX, 2027, at 5 p.m. ET.

Part 1. General Information
Complete this section with your organization’s basic information. An asterisk (*) indicates a required
response.
1.1 APPLICANT ORGANIZATION
1.1.a. ORGANIZATION NAME*
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1.1.b. MAILING ADDRESS 1*
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1.1.c. MAILING ADDRESS 2
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1.1.d. CITY*

1.1.e. STATE*

1.1.f. ZIP CODE*

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enter text.

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1.1.g. TELEPHONE AND FAX (area code, number and
extension)
TEL*

EXT

FAX

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text.

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to enter text.
enter text.

1.1.h. WEBSITE*
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text.

1.2 APPLICANT CONTACT PERSON
1.2.a. PRIMARY CONTACT PERSON
FIRST NAME*
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MIDDLE INITIAL* LAST NAME*
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enter text.
text.

1.2.b. TITLE*

1.2.c. DEGREE (e.g., RN, MD, PhD)

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1.2.d. MAILING ADDRESS 1*
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1.2.e. MAILING ADDRESS 2
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1.2.f. CITY*

1.2.g. STATE*

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enter text.
text.

1.2.i. TELEPHONE AND FAX (area code, number and
extension)
TEL*

EXT

FAX

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text.

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to enter text.
enter text.

1.2.h. ZIP CODE*

1.2.j. EMAIL ADDRESS*
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text.

1.3 CMS-SPONSORED AND CAHPS SURVEY EXPERIENCE
*1.3.a. Have you been approved as a vendor to implement
other CMS or CAHPS surveys in the past 5 years?

☐ Yes

☐ No

*1.3.b. Have you been a subcontractor to an approved
vendor for other CMS or CAHPS surveys in the past 5
years?

☐ Yes

☐ No

*1.3.c. If Yes, please provide the name of the survey vendor(s) and the survey(s) for which
you’ve been a subcontractor.
Click or tap here to enter text.

CMS will consider prior experience, as either a survey vendor or subcontractor on CMS or
CAHPS surveys, when reviewing your organization’s Participation Form.

Part 2. The CAHPS for MIPS Survey
2027 CAHPS for MIPS Survey Vendor Minimum Business Requirements
If you want to be a survey vendor for the CAHPS for MIPS Survey, you must meet the following
minimum business requirements. Please read each minimum business requirement below and
check Yes or No to indicate if you do or don’t meet each requirement. Please provide
supporting information where requested. An asterisk (*) indicates a required response.

2.1. RELEVANT ORGANIZATIONAL SURVEY EXPERIENCE
Recent experience (at least 3 years) in fielding surveys via Mixed-Mode (mail survey
administration followed by Computer-Assisted Telephone Interview [CATI] administration with
non-respondents).
*2.1.a. Survey experience: Within the last 5 years, do you have at
least 3 years of experience conducting surveys with the Medicare
population and administering CAHPS surveys?

☐ Yes

☐ No

2.1.b. Experience details: Complete this section with information from the 5 most recent
CAHPS and Medicare population survey projects in which your organization administered
surveys:
Survey *What was the survey name?
Project
#1
*What was the average sample size in the data collection
period?
*When did your organization collect data? (month/year of
start and end dates)

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text.
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text.
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text.
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*For how many clients did your organization administer this text.
survey?
*In which mode(s) did you administer the survey
(web-mail-phone, mail only, telephone only,
mail-phone, etc.)?
*In what language(s) did you administer the survey?

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text.
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text.

Survey *What was the survey name?
Project
#2
*What was the average sample size in the data collection
period?

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text.

*When did your organization collect data? (month/year of
start and end dates)

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text.

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text.

*For how many clients did your organization administer this Click or tap here to enter
text.
survey?
* In which mode(s) did you administer the
survey? (web-mail-phone, mail only, telephone
only, mail-phone, etc.)
*In what language(s) did you administer the survey?

Click or tap here to enter
text.
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text.

Survey *What was the survey name?
Project
#3
*What was the average sample size in the data collection
period?

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text.

*When did your organization collect data? (month/year of
start and end dates)

Click or tap here to enter
text.

Click or tap here to enter
text.

*For how many clients did your organization administer this Click or tap here to enter
text.
survey?
* In which mode(s) did you administer the
survey? (web-mail-phone, mail only, telephone
only, mail-phone, etc.)
*In what language(s) did you administer the survey?

Click or tap here to enter
text.
Click or tap here to enter
text.

Survey *What was the survey name?
Project
#4
*What was the average sample size in the data collection
period?

Click or tap here to enter
text.

*When did your organization collect data? (month/year of
start and end dates)

Click or tap here to enter
text.

Click or tap here to enter
text.

*For how many clients did your organization administer this Click or tap here to enter
text.
survey?
* In which mode(s) did you administer the
survey? (web-mail-phone, mail only, telephone
only, mail-phone, etc.)
*In what language(s) did you administer the survey?

Click or tap here to enter
text.
Click or tap here to enter
text.

Survey *What was the survey name?
Project
#5
*What was the average sample size in the data collection
period?

Click or tap here to enter
text.

*When did your organization collect data? (month/year of
start and end dates)

Click or tap here to enter
text.

Click or tap here to enter
text.

*For how many clients did your organization administer this Click or tap here to enter
text.
survey?
*In which mode(s) did you administer the
survey? (web-mail-phone, mail only, telephone
only, mail-phone, etc.)
*In what language(s) did you administer the survey?

*2.1.c. Number of years in business: Have you been in business
at least 4 years?

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text.
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text.
☐ Yes

☐ No

*2.1.d. Number of years conducting surveys: For at least
3 of the past 5 years, have you administered surveys using
mail-phone methodology (mail survey administration
followed by CATI administration with non-respondents)?

☐ Yes

☐ No

*2.1.e. Number of years conducting surveys: For at least 3
of the past 5 years, have you administered web-mode
surveys (web survey administration followed by mail survey or
CATI administration with non-respondents)?

☐ Yes

☐ No

*2.1.f. Experience with multiple survey languages: Do you have
experience administering surveys in English, Spanish, and at least
one other language from the list at right?

☐ Yes

☐ No

If yes, please check the languages other than English and Spanish
in which you’ve administered surveys.

☐ Cantonese
☐ Mandarin
☐ Korean
☐ Russian
☐ Vietnamese
☐ Portuguese

Note: The 3 years of mail-CATI experience must be fulfilled by
the applicant vendor and not its subcontractor.

2.2. ORGANIZATIONAL SURVEY CAPACITY
Capability and capacity to handle a required volume of mail questionnaires and conduct
standardized telephone interviewing in a specified time frame.
*2.2.a. Designate key survey personnel: Does your organization
have a:
• Project Manager who has administered mail-phone
surveys for at least 3 years; and
• Web Survey Manager who has administered web
mode surveys that include follow-up of non-response
via mail survey or CATI for at least 3 years; and
• Web Survey Programmer with survey experience for a
minimum of 1 year; and
• Information Systems Specialist/Computer
Programmer/Developer with survey experience for a minimum
of 1 year; and
• Mail Survey Supervisor (with a minimum of 1 year of prior
experience in the role); and
• Telephone Survey Supervisor (with a minimum of 1 year of
prior experience in the role); and
• Organizational back-up staff to cover key staff?
Notes:
1. Volunteers aren’t permitted to be involved in any aspect of the
survey administration process.
2. Your organization must complete security training, develop
confidentiality agreements, and obtain signatures annually from all
personnel (including subcontractor staff) involved in survey
administration and data collection.

☐ Yes

☐ No

*2.2.b. System resources: Does your organization have a secure
commercial workplace with the physical plant resources to handle
the volume of surveys being administered, including:
• Computer and technical equipment; and
• An electronic survey management system to track
fielded surveys through the entire protocol?

☐ Yes

☐ No

☐ Yes

☐ No

*2.2.c.2. You acknowledge that telephone interviews may be
conducted remotely if your organization adheres to the remote work
guidelines in the CAHPS for MIPS Survey Quality Assurance
Guidelines Version 2027? ±

☐ Yes

☐ No

*2.2.d.1. Data submission:

☐ Yes

☐ No

Note: All system resources are subject to oversight activities,
including site visits to physical locations (such as a vendor’s
mail facility to observe production of survey materials, facility
housing the systems/servers or staff supporting the web
survey, and/or a call center where interviews are being
conducted).
*2.2.c.1. Web-Mail-Phone survey administration: Your
organization will be given the web, mail, and telephone versions of
the CAHPS for MIPS Survey in electronic form and text for web survey
invitations (letters and emails) and survey cover letters.
Can your organization:
• Generate and send emails, print and copy survey materials, and
program electronic data collection in accordance with the
specifications, templates, and timeline provided; and
• Use commercial software/resources to ensure that the
addresses and telephone numbers are up-to-date for all
sampled patients; and
• Process survey returns and remove applicable records from
additional outreach; and
• Keep the information that identifies the people taking part in
the survey confidential?
.

Can your organization encrypt data files for transmission in
accordance with required specifications?

*2.2.d.2. Does your organization have previous experience with 8-bit
Unicode Transformation Format (UTF-8) or 16-bit Unicode
Transformation Format (UTF-16) files, and submitting encrypted data
to an external data warehouse?

☐ Yes

☐ No

*2.2.d.3. Will authorizations and business associate agreements be
established between your organization and the group, virtual group,
Alternative Payment Model (APM) Entity, or Shared Savings
Program Accountable Care Organization (ACO)?

☐ Yes

☐ No

*2.2.e. Data security: Can your organization register with the CMS
Contractor and follow data specifications and procedures in order to
send and receive encrypted data from the Internet?

☐ Yes

☐ No

*2.2.f. Confidentiality: Can your organization meet all Health
Insurance Portability and Accountability Act (HIPAA) rules and
regulations and store survey-related paper, scanned images, audio
recordings or electronic data files, including sample information and
submitted data, securely and confidentially for a minimum of 6
years?

☐ Yes

☐ No

*2.2.g. Technical assistance/customer support: Can your
organization provide customer support via email and phone and
respond within 24-48 hours to all languages in which you’re
administering the survey?

☐ Yes

☐ No

Note: Organizations must ensure protected health information (PHI)
and/or personally identifiable information (PII) will only be transmitted
and exchanged using secure methods. Emailing PHI or PII via
unsecure email is prohibited.

2.3 QUALITY CONTROL PROCEDURES
Personnel training and quality control mechanisms used to collect valid, reliable survey data.
*2.3.a. Demonstrated Quality Control Procedures: Can your
organization set up and document quality control procedures for all
phases of survey implementation including: training; customer
support line operations; web survey administration via https;
printing, mailing and recording receipt of surveys; telephone
administration of survey (electronic telephone interviewing system);
coding, editing, or keying in survey data; preparing final person-level
data files for submission; and all other functions and processes that
affect the administration of the CAHPS for MIPS Survey?
2.3.b. Can your organization provide documentation as requested for
site visits and conference calls, including but not limited to: HIPAA
compliance, web email and letter production, mail material
production, staff training records, telephone interviewer monitoring
records, and file construction documentation?
2.4 EXPLANATION
Please explain why you replied “NO” to any of the questions in Section 2.
Click or tap here to enter text.

☐ Yes

☐ No

☐ Yes

☐ No

Part 3. Key Project Staff
3.1.a. LIST OF KEY PROJECT STAFF
*Project staff name

Role

Email

Telephone

1.

Project Manager

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enter text.

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enter text.

Web Survey Manager

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enter text.

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enter text.

Web Survey Programmer

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enter text.

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enter text.

Mail Survey Supervisor

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enter text.

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enter text.

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enter text.

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enter text.

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enter text.

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2.
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3.
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4.
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5.
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6.
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Telephone Survey
Supervisor
Information Systems
Specialist/Computer
Programmer/Developer

Part 4. Costs Associated With Survey Administration
4.1 Cost of Survey Administration
Please indicate a minimum and maximum dollar value associated with the range of costs for
administration of the CAHPS for MIPS Survey in English and Spanish using the mail-phone
survey administration protocol detailed in the CAHPS for MIPS Survey Quality Assurance
Guidelines Version 2027 for a sample of 860 patients. The minimum and maximum values
you enter will be reported together as a cost range.
Enter dollar values in whole numbers without any symbols:
Minimum dollar value:
Maximum dollar value:
Indicate whether the dollar values entered above are:
☐ Per sampled patient
☐ Per sample of 860 patients
Optional: Please describe the factors associated with your range of costs (e.g., what factors
result in costs closer to the minimum value and what factors result in costs closer to the
maximum value?), and any clarification of why cost may vary. (Maximum of 500 characters)

4.2 Cost of Optional Translation
Please indicate a minimum and maximum dollar value associated with the range of costs for a
group, subgroup, virtual group, or APM Entity (including Shared Savings Program ACOs) to
include one of the optional language translations provided by CMS. Dollar values should
indicate the range of costs that would be added to the cost of survey administration using the
required languages of English and Spanish. The minimum and maximum values you enter will
be reported together as a cost range.
Enter dollar values in whole numbers without any symbols:
Minimum dollar value:
Maximum dollar value:
Indicate which language or languages are included in the dollar values entered above
(Mark All That Apply):
☐ Cantonese
☐ Korean
☐ Mandarin
☐ Portuguese
☐ Russian
☐ Vietnamese
Indicate whether the dollar values entered above are:
☐ Per sampled patient
☐ Per sample of 860 patients
Optional: Please describe the factors associated with your range of costs (e.g., what factors
result in costs closer to the minimum value and what factors result in costs closer to the
maximum value?), and any clarification of why cost may vary. (Maximum of 500 characters)

Part 5. List of Subcontractors
5.1.a. ☐ Check here if your organization doesn’t plan to use subcontractors for the 2027
survey administration and skip to Part 5. If your organization will use subcontractors, fill
out the following about your organization’s subcontractors.
5.1.b. Subcontractor name and experience
Subcontractor 1 Name, Address,
Telephone Number, and Primary Contact:

What will the subcontractor do in administering
the 2027 CAHPS for MIPS Survey?

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Click or tap here to enter text.

How many years has your organization worked with the subcontractor? Click or tap here to
enter text.
How many years has the subcontractor administered surveys? Click or tap here to enter text.
How many years has the subcontractor been in business? Click or tap here to enter text.
What experience does the subcontractor have related to how it will administer the CAHPS for
MIPS Survey?
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What general survey experience does the subcontractor have?
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Subcontractor 2 Name, Address,
Telephone Number, and Primary Contact:
Click or tap here to enter text.

What will the subcontractor do in administering
the 2027 CAHPS for MIPS Survey? Click or
tap here to enter text.

How many years has your organization worked with the subcontractor? Click or tap here to
enter text.
How many years has the subcontractor administered surveys? Click or tap here to enter text.
How many years has the subcontractor been in business? Click or tap here to enter text.
What experience does the subcontractor have related to how it will administer the CAHPS for
MIPS Survey?
Click or tap here to enter text.
What general survey experience does the subcontractor have?
Click or tap here to enter text.

NOTE: Add additional subcontractor information in a separate document.

Part 6. Curriculum Vitae (CV)
6.1. Please email CVs for all of your key project staff listed in Table 3.1.a. List of Key Project
Staff via the CAHPS for MIPS Survey Technical Assistance email at [email protected].

Part 7. Rules of Participation
Any organization participating in the CAHPS for MIPS Survey must adhere to the
following Rules of Participation. To be eligible, the organization must:
1. Take part in a teleconference with the Project Team to talk about your organization’s
relevant survey experience, organizational survey capability and capacity, quality
control procedures, and role of subcontractors (if applicable).
2. Take part in and successfully complete all training sessions. In addition to the Project
Manager, we require the following staff to attend training, as applicable: Web Survey
Manager, Web Survey Programmer, Mail Survey Supervisor; Telephone Survey
Supervisor; Information Systems Specialist and Computer Programmer/Developer;
Data Administrator; and Back-up Data Administrator. Your organization’s
subcontractors that have key roles in administering the survey are also required to
attend training.
3. Review and follow the CAHPS for MIPS Survey Quality Assurance Guidelines
Version 2027 and policy updates.
4. Attest to the accuracy of your organization’s data collection (as determined by
CMS), following guidelines in the most current version of the CAHPS for MIPS
Survey Quality Assurance Guidelines Version 2027.
5. Write and send a Quality Assurance Plan (QAP) by the due date. Also, send in
materials relevant to the survey administration (as determined by CMS),
including web survey materials (e.g., email templates, invitation letters, testing
links), mailing materials (e.g., cover letters, envelopes, and questionnaires) and
telephone scripts.
6. Participate and cooperate in all oversight activities conducted by the Project Team
(including subcontractors).
7. Send in an interim and final survey data file(s) to CMS.
8. Acknowledge that review of, and agreement with, the Rules of Participation is
necessary for participation and public reporting of results on the compare tool of
the Medicare.gov website.

Part 8: Applicant Organization Qualification and Acceptance
I certify that:
•

•

*AUTHORIZED REPRESENTATIVE:

I have reviewed and agree to meet the
Rules of Participation for participating in the Name: __________________________________
CAHPS for MIPS Survey.
The statements herein are true, complete, Title: ____________________________________
and accurate to the best of my knowledge,
and I accept the obligation to comply with Organization: _______________________________
the 2027 CAHPS for MIPS Survey Vendor
Date: __________________________________
Minimum Business Requirements.

If you need help completing this application, please contact the Project Team by email at
[email protected].
When you complete the form, send it as an attachment to [email protected].
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1222 (Expiration date: TBD). The time required to
complete this information collection is estimated to average 11 hours per response, including the
time to review instructions, search existing data resources, gather the data needed, and complete
and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that
any correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If
you have questions or concerns regarding where to submit your documents, please contact
[email protected].

±

Survey vendors approved for 2027 survey administration may conduct this component of the 2027 Mixed-Mode business
requirements remotely. Vendors must adhere to the remote work guidelines in the CAHPS for MIPS Survey Quality
Assurance Guidelines Version 2027 and continue to adhere to the vendor approval criteria codified in §414.1400 (PDF,
200KB) throughout the 2027 administration of the survey.