Survey Vendor Authorization Form
Print all three pages of the Survey Vendor Authorization Form.
Follow the instructions to completely fill out pages two and three.
“Hospice Administrator First and Last Name” on page two refers to the hospice’s job title administrator.
The “Hospice Point of Contact” on page two is the CAHPS® contact for the CAHPS® Hospice survey project team.
Reference Pinnacle Quality Insight on page two as the CAHPS® Hospice Survey vendor name and on the top of page three under Survey Vendor Authorizing.
This form must be notarized, per the instructions on page three.
Mail all three pages to the RAND Corporation at the address provided on the form. You may include the Data Warehouse form when mailing the Survey Vendor Authorization Form. We recommend mailing the form with proof of delivery.
Contact Angell Hanson, CAHPS® Account Manager at Pinnacle Quality Insight, if you have questions about how to submit the required forms or if you need assistance.