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Home Health Care CAHPS Survey
Web Mode Experiment Interest Form

Please complete this form if your home health agency is interested in participating in the HHCAHPS Web Mode Experiment. More information about participation, including Frequently Asked Questions (FAQs), can be found here.

You and your HHCAHPS Survey vendor will receive an email confirmation of your participation after you click the Submit button.

NOTE: The submission of this form notifies the HHCAHPS Survey Coordination Team of your agency's interest in participating in the HHCAHPS Web Mode Experiment. If your agency is selected to participate, you will be contacted before this effort begins.

*1. Enter your agency's 6-digit CMS Certification Number (CCN, formerly known as the Medicare Provider Number), then click the button beside the number that you entered. NOTE: To sign up more than one CCN, enter one CCN here; select "Yes" in item #1a below, and send a list of the CCNs to the Coordination Team at hhcahpsmode@rti.org.
 
  Agency name shown reflects information in the most current list of CMS agencies. Please contact hhcahpsmode@rti.org if this does not match your agency's name.
1a. If you want to sign up more than one CCN, select "Yes" and send a list of the CCNs to hhcahpsmode@rti.org. Right arrow
*2. Agency Contact's First Name Right arrow
*3. Agency Contact's Last Name Right arrow
*4. Agency Contact's E-mail Address Right arrow
*5. Confirm E-mail Address Right arrow
*6. Agency Contact's Telephone Number (include area code) Right arrow
*7. I give authorization for my HHCAHPS Survey vendor to give unused sample each month to RTI for use in the Web mode experiment, for the sample months of September, October, and November 2021. Right arrow
*8. My HHCAHPS Survey vendor for the September, October, and November 2021 months is: Right arrow
*9. My agency can or will attempt to provide patient email addresses if selected. Right arrow
10. I have a question about participation and would like someone from the HHCAHPS Survey Coordination Team to call me. Right arrow
11.
* required fields