RY2012 MassHealth Acute Hospital RFA: Hospital Quality Contacts Form

Instructions Pursuant to Section 7 of the Acute Hospital RFA, each Hospital must 
complete and submit information on all staff involved in quality reporting. Please
enter all information required of each designated staff in blank spaces under the
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.

Hospital Name: Hospital CEO Name: 

Street Address: Phone: 

City: State: Fax: 

Zip Code: E-mail:

Hospital Key Quality Contact

Name

Title/Dept.

E-mail

Phone

Fax

Address

City

State

Zip

Acute Hospital RFA Contract Manager 

Name

Title/Dept.

Fax

E-mail

Phone

Address

City

Zip

State

MassQEX Portal Registered Users

MassQEX User 1 Name

Title/Dept.

E-mail

Phone

Fax

E-mail

Phone

Fax

MassQEX User 2 Name

Title/Dept.

MassQEX User 3 Name

Title/Dept.

E-mail

Phone

Fax

Note: Hospitals must use this form to notify MassHealth of any changes to key staff listed,
during RFA contract period, as as soon as information is available.

Above changes are effective as of (enter date): Authorized Quality Contact Signature: 

HospContact_2012 Form

Executive Office of Health and Human Services