Vendor Authorization
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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 2018 begins with October 2018 patient deaths (caregivers to be surveyed January 2019).

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.

If sent via U.S. Mail, send to:

 RAND Corporation 
 ATTN: Melissa A. Bradley 
 CAHPS Hospice Survey 
 1200 South Hayes Street 
 Arlington, VA 22202

If sent via Federal Express, UPS or other overnight delivery service, send to:

RAND Corporation 
ATTN: Melissa A. Bradley 
CAHPS Hospice Survey 
1200 South Hayes Street 
Arlington, VA 22202 
Phone: 703-413-1100, 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.

Note: If a hospice wishes to change CAHPS Hospice Survey vendors, it may do so ONLY at the beginning of a calendar quarter. A quarter is based on the calendar year and corresponds to the month of patient death. • Quarter 3 2018 begins with July 2018 patient deaths (caregivers to be surveyed October 2018) • Quarter 4 2018 begins with October 2018 patient deaths (caregivers to be surveyed January 2019) • Quarter 1 2019 begins with January 2019 patient deaths (caregivers to be surveyed April 2019) • Quarter 2 2019 begins with April 2019 patient deaths (caregivers to be surveyed July 2019) • Quarter 3 2019 begins with July 2019 patient deaths (caregivers to be surveyed October 2019) • Quarter 4 2019 begins with October 2019 patient deaths (caregivers to be surveyed January 2020)