Hospital Quality Alliance (HQA) Initiative
Forms:
Pledge (Sign Up) for HQA:
To sign up for HQA, hospitals must complete the Pledge of Participation form for the Hospital Quality Alliance and fax it to the
AHA. To make changes later, either submit a new form or have the hospital CEO/administrator initial and date changes made on the original form; then fax to the AHA. (Please also fax a copy of the pledge
form to AFMC in Little Rock, attn: Nancy
Archer, HCQIP manager, at
501-375-5705, so that electronic
flags may be set.)
Obtain the pledge form from www.qualitynet.org or contact AFMC at 877-375-5700 and ask for a member of the hospital team.
Please mail original form to:
Attention: Vickie Krebs
AFMC
401 West Capitol, Suite 508
Little Rock, AR 72201
SEND ORIGINALS.
Withholding Data in the HQA:
Hospitals have 30 days to preview data
that will be posted to www.cms.hhs.gov.
During this time period a hospital may elect to withhold
certain measure(s)
by completing a Request
for Withholding Data from Public Reporting form. The hospital's
data for measure(s) that were withheld for that reporting
period would be posted for the next reporting period unless
the hospital withholds again or withdraws from HQA.
(To obtain the withholding form click link below. Fax copy of completed
form to Nancy Archer at 501-375-5705.)
Obtain form from www.qualitynet.org or contact AFMC at 877-375-5700 and ask for a member of the hospital team.
Please mail original form to:
Attention: Vickie Krebs
AFMC
401 West Capitol, Suite 508
Little Rock, AR 72201
SEND ORIGINALS.
Withdrawal of Participation from HQA:
A hospital has 30 days to preview data
that will be posted to public Web sites. During this time
period a hospital may elect to completely withdraw from
the HQA by completing a Withdrawal of Participation
in the Hospital Quality Alliance form. Fax the completed form to: Nancy Archer, HCQIP manager, AFMC – Little
Rock, at 501-375-5705. If the hospital chooses to pledge
again at a later date, administrators must complete
another
pledge
form
Please note that for an acute PPS hospital to receive the full market basket update for RHQDAPU, you must report the required quality measure set.
Please mail original form to:
Attention: Vickie Krebs
AFMC
401 West Capitol, Suite 508
Little Rock, AR 72201
SEND ORIGINALS.
Obtain form from www.qualitynet.org or contact AFMC at 877-375-5700 and ask for a member of the hospital team.
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