Hospital Contact Change Form - Quality Net

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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/CCN:
___________________
Name/Title 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
(Infection Prevention)
Quality Management/
Improvement Contact
*QualityNet Security
Administrator (SA)
*Important Note about QualityNet SAs: Every facility participating in the IQR and/or IPFQR Program must designate a minimum of one SA. To prevent possible interruption of
QualityNet access, facilities are highly encouraged to appoint at least two SAs. If your facility does not have one, it may be at risk of having one-fourth of its Inpatient Prospective
Payment System (IPPS) annual payment update (APU) withheld. For more information about how to designate an SA, please refer to the SA Registration page on the QualityNet
website:
under Inpatient Hospitals > Hospital Inpatient Quality Reporting Program > How to Participate > QualityNet Registration > Security
Administrator.
Please Note: Submitting SA contact information on this form WILL NOT update or change your SA information in QualityNet.

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