EOHHS-MassHealth

Hospital Name(Required)

Hospital Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Hospital CEO Name(Required)

First Last

Hospital CEO Phone(Required)

Hospital CEO Fax Number

Hospital CEO Email(Required)

Key Quality Representatives (Acute RFA)

Please enter the two key quality representatives who will serve as primary contacts for the CQI program, as outlined in Section 7B of the Acute Hospital RFA.

Key Quality Contact Name(Required)

First Last

Key Quality Contact Title/Department(Required)

Key Quality Contact Email(Required)

Key Quality Contact Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Key Quality Contact Phone(Required)

RFA Finance Contact Name(Required)

First Last

RFA Finance Contact Title/Department(Required)

RFA Finance Contact Email(Required)

RFA Finance Contact Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

RFA Finance Contact Phone(Required)

MassQEX Portal User Accounts

Please enter up to 5 hospital staff users. If your hospital has fewer than 5 users, please enter n/a in the fields that do not apply.

Hospital Staff User Name1(Required)

Hospital Staff User Name1 Title/Department(Required)

Hospital Staff User Name1 Email(Required)

Hospital Staff User Name1 Phone(Required)

Hospital Staff User Name2(Required)

Hospital Staff User Name2 Title/Department(Required)

Hospital Staff User Name2 Email(Required)

Hospital Staff User Name2 Phone(Required)

Hospital Staff User Name3(Required)

Hospital Staff User Name3 Title/Department(Required)

Hospital Staff User Name3 Email(Required)

Hospital Staff User Name3 Phone(Required)

Hospital Staff User Name4(Required)

Hospital Staff User Name4 Title/Department(Required)

Hospital Staff User Name4 Email(Required)

Hospital Staff User Name4 Phone(Required)

Hospital Staff User Name5(Required)

Hospital Staff User Name5 Title/Department(Required)

Hospital Staff User Name5 Email(Required)

Hospital Staff User Name5 Phone(Required)

Medical Record SFTP User Name(Required)

Medical Record SFTP User Name Title/Department(Required)

Medical Record SFTP User Name Email(Required)

Medical Record SFTP User Name Phone(Required)

Third-Party Data Vendor Accounts

Vendor Lead Contact Name(Required)

First Last

Agency Name and Title(Required)

Vendor Lead Contact Email(Required)

Vendor Lead Contact Phone(Required)

Submission Information

Person Submitting Form(Required)

First Last

Email(Required)

Date Effective(Required)