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Each Medicare-certified home health agency must complete the following steps to register for credentials to access the private links on the HHCAHPS website. The Consent Form must be completed by the agency's designated HHCAHPS Survey Administrator.
- In the form below, type in your agency's CCN (formerly known as the MPN), the agency name, and the name and contact information of the person your agency is designating as its Survey Administrator. Note that all e-mail communications from the HHCAHPS Coordination Team will be sent to the person that your agency designates as its HHCAHPS Survey Administrator (at the e-mail address that you provide below). Click the "Continue" button to confirm your information.
- Once you enter the information requested in Step 1 above, the system will ask you to confirm the information that you entered.
- After you confirm that information, the system will automatically create and display a personalized two-page Consent Form (CF) for your agency. Please confirm that the CCN(s) and agency name(s) on page 2 is correct, and then print the CF and have it notarized. Send both pages of the CF to the HHCAHPS Coordination Team. Only originals will be accepted; do not send copies of the notarized form. Note the following.
- You must have the most recent version of the Adobe Reader software in order to view the personalized CF. If you receive the following error message: "This file has been damaged and cannot be repaired," download and install the newest version of Adobe Reader, which is available at the following link: http://get.adobe.com/reader. Then try to print the CF again.
- If the designated Survey Administrator will represent more than one HHA, you may include up to 45 CCNs on one Consent Form. If you have more than 45 agencies, please complete a new registration form for any CCNs beyond the initial 45.
- The HHCAHPS Survey Coordination Team will send password information to the registered Survey Administrator via an email message as soon as we receive your registration. However, you will still be required to mail the notarized Consent Form to the Coordination Team.
- The HHCAHPS Coordination Team will not send you a confirmation that we have received your Consent Form. However, we will contact you if there is a problem with the form we receive from you.
If the Survey Administrator has an existing login account, the Survey Administrator should first log onto the HHCAHPS website then complete this registration form. This will link all of that person's CCNs under a single account (e.g., the same login credentials).
By providing your contact name and email information below, you are registering as the Survey Administrator for your agency. You will be responsible for adding or removing users to this account. If you do not wish to be designated as the Survey Administrator for your agency, please provide a different contact name and email address for the Administrator role.