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Special notices for acute hospitalsMass.gov

Special notices for acute hospitalsMass.gov 2025

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The document is a form for the RY2020 MassHealth Acute Hospital Pay-for-Performance Program, requiring hospitals to provide key information about staff involved in quality reporting. It includes sections for hospital details, key quality contacts, authorized data contacts, and mailing instructions for submission.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Hospital Key Information. Fill in the hospital name, CEO name, street address, phone number, city, state/zip, fax, and email in the designated fields.
Next, move to the Hospital Key Representatives section. Input the key quality contact's name and position/title along with their contact details including street address, phone number, city, state/zip, fax, and email.
Continue to fill out the RFA Manager Contact section with similar details: name, position/title, and contact information.
For Authorized MassQEX Data Contacts, provide names and titles for each contact along with their emails and phone numbers. Ensure all fields are completed accurately.
Finally, sign in the Key Representative Signature section and include the date signed. Remember to follow mailing instructions for submission.

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Versions	Form popularity	Fillable & printable
2023	4.9 Satisfied (45 Votes)
2021	4.8 Satisfied (42 Votes)
2020	4 Satisfied (34 Votes)
2014	4.8 Satisfied (63 Votes)

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