RY2013 MassHealth Acute Hospital RFA: Hospital Quality Contacts Form
Executive Office of Health and Human Services
Hospital name: Hospital CEO name:
Street address: Phone:
City: State: Fax:
Zip code: E-mail:
HospContact_2013 Form
Hospital RFA Quality Contact
Name Title/Dept.
Mailing address
E-mail
City
State
Phone Fax
Zip code
Name Title/Dept.
Mailing address
E-mail
City
State
Phone Fax
Zip code
Hospital RFA Manager Contact
MassQEX Portal Registered Users
User Name 1
User Name 2
Title/Dept.
Title/Dept.
E-mail
E-mail
Phone
Phone
Fax
Fax
Instructions: Pursuant to Section 7.2 of the Acute Hospital RFA, each hospital must submit current information on key representatives designated to communicate with
EOHHS on all aspects of pay-for-performance measures reporting. Please enter all information required for each designated sta in blank spaces under each section header. All
information must be typed in this Adobe PDF form using Adobe Reader version 5 or higher. Go to http://get.adobe.com/reader/ to download Adobe Reader.
Note: Hospitals must use this form to notify MassHealth of any changes to key contacts listed, during RFA contract period, as soon as information is available. Blank forms can
be obtained by sending a request to the EOHHS mailbox at: masshealthhospitalquality@state.ma.us
Above information is current as of (enter date): Authorized Quality Contact Signature:
Title/Dept. E-mail Phone FaxUser Name 3
