RY2020 MassHealth Acute Hospital Pay-for-Performance Program
Hospital Quality Contacts Form
INSTRUCTIONS: Pursuant to the Acute Hospital RFA (Section 7), each Hospital must complete and submit information on sta
involved in quality reporting during the rate year. All information in blank spaces must be typed on this PDF form.
Hospital Key Information
HOSPITAL NAME HOSPITAL CEO NAME
Street address Phone Fax
City State/Zip Email
Hospital Key Representatives
Key Quality Contact Name Position/Title
Street Address Phone Fax
City State/Zip Email
RFA Manager Contact Name Position/Title
Street Address Phone Fax
City State/Zip Email
Authorized MassQEX Data Contacts
MassHealth NHSN Contact Name Title Email Phone
MassQEX Hospital User Name Title Email Phone
MassQEX Hospital User Name Title Email Phone
MassQEX Hospital User Name Title Email Phone
MassQEX Hospital User Name Title Email Phone
MassQEX Hospital User Name Title Email Phone
Data Vendor User Name Agency Email Phone
Data Vendor User Name Agency Email Phone
Data Vendor User Name Agency Email Phone
Key Representative Signature: Date Signed:
MAILING INSTRUCTION: Mail the complete and signed form
along with a typed cover letter on hospital stationery to the
address on the right:
EOHHS MassHealth Acute Hospital P4P Program,
100 Hancock Street (6
th
floor)
Quincy, MA 02171.
HospContact_2020 Form
