CAHPS Hospice Survey Vendor Authorization Form
Hospice agencies must authorize an approved CAHPS Hospice Survey vendor to submit data on their behalf for the administration of the CAHPS Hospice Survey.
In order to authorize a survey vendor or switch to a new vendor, a hospice representative must complete the CAHPS Hospice Survey Vendor Authorization Form and submit it to the RAND Corporation one calendar quarter (90 days) prior to the first time data will be submitted to the CAHPS Hospice Survey Data Warehouse by that vendor. The individual who completes this form for the hospice will be considered the CAHPS Hospice Survey Administrator for that hospice. Hospices should also designate, on the form, an individual within the hospice organization to serve as the main point of contact with the CAHPS Hospice Survey Project Team.
If a hospice wishes to change CAHPS Hospice Survey vendors, it may do so ONLY at the beginning of a calendar quarter. Note: A quarter is based on the calendar year (CY) and will correspond to the month of patient death. For example, Quarter 4 2022 begins with October 2022 patient deaths (caregivers to be surveyed January 2023).
Click here to download the CAHPS Hospice Survey Vendor Authorization Form.
The CAHPS Hospice Survey Vendor Authorization Form must be signed and dated in the presence of a notary public, notarized and sent to the RAND Corporation. Please note, when completing a CAHPS Hospice Survey Vendor Authorization Form pertaining to multiple hospice agencies, it is appropriate to attach a list to the form (signed and dated by the CAHPS Hospice Survey Administrator) of all the hospices (hospice names and CMS Certification Numbers [CCNs]). Please check the box on the form indicating that a separate document is attached and indicate the number of hospice names and CCNs listed on the separate sheet.
Send the completed form to:
ATTN: Survey Research Group - Data Reduction
CAHPS Hospice Survey
1776 Main Street
Santa Monica, CA 90401
Phone: 310-393-0411, extension 5599
Note: After submission of the CAHPS Hospice Survey Vendor Authorization Form, no further action is required by the hospice to notify CMS of their survey vendor selection. The RAND Corporation communicates to CMS which hospice agencies have authorized a survey vendor to administer the CAHPS Hospice Survey on their behalf. The RAND Corporation notifies vendors of hospices who have authorized them for data collection. Vendors cannot submit data for hospices that have not authorized them.