Street Address Line 2
State / Province
Postal / Zip Code
Primary Contact Name
Primary Contact Email
Please enter a valid phone number.
Number of individual locations enrolling in benchmarking:
Select the Benchmarking Program(s) for Participation
Status at Discharge
Is the provider using the NHIF Uniform Patient Satisfaction Survey Questions for Home Infusion Providers?
Do you currently utilize a third-party to administer patient satisfaction surveys?
If yes, what is the name of the third-party administrator?
Do you offer patients the option to receive a paper survey?
Do you currently survey patients at the time of discharge?
Do you survey active, long term patients and plan to include it in the data submitted?
Status at Discharge and 30-Day Rehospitalization
Review and agree to use standardized terms and definitions for the following
Standardized therapy categories
Standardized list of access devices
Standardized definitions for outcome data elements
Should be Empty: