Hospital Contact Change Form - Quality Reporting Center

Hospital Contact Change Form

Only provide information for the contact types that need to be updated or corrected.

Form may be faxed to 877-789-4443 or sent by email to

Date:

____________________

Provider Name: _____________________

Provider ID:

___________________

Name of Person Completing the Form: __________________________________

Phone Number:

____________________

Contact Type

Contact Name

Contact Title

Telephone Number

Fax Number

Email Address

CEO/Administrator

Inpatient Quality

Reporting (IQR)

Contact

Outpatient Quality

Reporting (OQR)

Contact

Inpatient Psych

Facility (IPF)

Contact

PPS-Exempt Cancer

Hospital Contact

Medical Record

Contact

National Healthcare

Safety Network

(NHSN) Contact

*QualityNet Security

Administrator(1)

QualityNet Security

Administrator(2)

* It is a requirement of the Quality Reporting Program that each hospital have at least one active SA. If your facility does not have one, it may be at risk of having a portion their

annual payment update (APU) withheld.