Organization Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact Name
*
First Name
Last Name
Primary Contact Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Number of individual locations enrolling in benchmarking:
insert number
.
Select the Benchmarking Program(s) for Participation
*
Patient Satisfaction
Status at Discharge
30-Day Rehospitalization
Patient Satisfaction
Benchmarking Metric
Is the provider using the NHIF Uniform Patient Satisfaction Survey Questions for Home Infusion Providers?
Yes
No
Other
Do you currently utilize a third-party to administer patient satisfaction surveys?
Yes
No
If yes, what is the name of the third-party administrator?
Do you offer patients the option to receive a paper survey?
Yes
No
Do you currently survey patients at the time of discharge?
Yes
No
Do you survey active, long term patients and plan to include it in the data submitted?
Yes
No
Status at Discharge and 30-Day Rehospitalization
Benchmarking Metrics
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
Submit
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