CMS CART Reporter
Hospital Authorization for Vendor
Transmission to IFQHC
TO: Amy Panagopoulos
Illinois Foundation for Quality Health Care
2625 Butterfield Road, Suite 102E
Oak Brook, IL 60523-1234
Phone: 800-386-6431
Fax: 630-571-5611
FROM:
CEO/Administrator Name:_________________________________________
Hospital name___________________________________________________
Address________________________________________________________
SUBJECT: Authorization for Hospital-Collected Data Transmission to: Illinois
Foundation for Quality Health Care (QIO)
________________________________ authorizes COMPdata,
Joint Commission certified Performance Measurement System (PMS), to transmit data on the
following topic(s) as of the specified discharge dates by topic:
| ______ Acute Myocardial Infarction | Effective with discharges beginning __________ |
| ______ Heart Failure | Effective with discharges beginning __________ |
| ______ Pneumonia | Effective with discharges beginning __________ |
| ______ SCIP | Effective with discharges beginning __________ |
The PMS contact information is as follows:
| Joint Commission ID #0339-01 | Contract Start Date: __________ |
| Name: COMPdata | E-mail: perfmeas@ihastaff.org |
|
Address: 1151 E. Warrenville Road City/Town: Naperville, Illinois 60566 |
|
|
Telephone: Illinois: 630.276.5889 Outside Illinois: 800.634-4248 |
Fax: 630/505-9389 |
The PMS agrees to transmit data via QualityNet into the QIO clinical
warehouse in the agreed-upon data format
provided by CMS. The data collected has also met the CMS 7th SOW standard abstraction protocols. The PMS ensures that all of its data
collection and transmission activities are in accordance with all HIPAA
regulatory requirements regarding security and privacy.
This authorization remains in effect for the specified PMS until the
CEO/Administrator of the hospital submits changes to the QIO.
Authorized by: __________________________________
(Signature of Administrator/CEO)
Print name: _____________________________________
Medicare Provider #: ______________________________
Effective Date: ___________________________
*** Please remember to send a copy of this form to COMPdata.