OAS-CAHPS

513-821-6266

Voluntary period sign-up is only $5.

Required Field

OAS-CAHPS Online Registration

Please complete the form below to sign up for OAS-CAHPS.  You will receive a call from Patrick Colletta within 1 business day regarding next steps.

500 Characters left
Billing Information
Credit Card

I authorize Fields Research to make recurring charges to my Credit/Debit card listed above, and if necessary, to initiate adjustements for any trasactions credited or debited in error. This authority will remain in effect until Fields Research has received written notification from me to cancel it. Notice must be received by Fields Research within seven days prior to the recurring charge date in order to cancel the next payment. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

e-Check
Check Information

I certify that I am an authorized representative of the Company indicated above and that I have the authority to enter into this Agreement on the Company’s behalf. Company understands that this authorization will remain in effect until it is canceled in writing, and agrees to notify Fields Research in writing at least 15 days in advance of any changes in its account information or termination of this authorization.In the case of a check being rejected for Non Sufficient Funds (NSF) Company understand that Fields Research may at its discretion attempt to process the charge again within 30 days, and agrees to an additional $30 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment.

Remit payment to the following address:

Fields Research, Inc.
3814 West Street
Suite 110
Cincinnati, OH 45227

If you have any questions please contact the FieldsResearch OAS-CAHPS® Team (513) 821-6266