Presentation on theme: "Completing Facility Security Administrator QualityNet Identity Provisioning System (QIPS) Registration Form."— Presentation transcript:
1 Completing Facility Security Administrator QualityNet Identity Provisioning System (QIPS) Registration Form
2 What to Know About Your Facility’s Security Administrators (SA) To utilize CROWNWeb (CW) each facility must designate:a Facility Security Administrator (SA)a Backup SA.SA’s role:create and update usersreset passwordsdisabling usersSubmit user forms for activationAn SA can also serve as a facility editor and do data entry.A person can only be an SA for one facility. However, an individual can be a user at more than one facility (scope).A facility may have any number of user/editors or persons with only viewing rights. Every person accessing CW must apply for a QIPS account, but does not require administrative rights.
3 Getting StartedWhere to get the QIPS form: https://www.qualitynet.org/crown/registration_form.pdf
4 Completing the form Requests, Roles, and Dates Type of RequestCheck Create new user accountQIPS RoleCheck the Security AdministratorDate RequestThe QIPS/ID section is for existing users only (leave blank)
5 Personal Information Section Things that need to be completed: (All field with asterisks *)First and Last NamePersonal address, City, State, Zip CodeBirth dateFields without asterisks are optional.
6 Identification Information (All field with asterisks (*) are Mandatory!)Provide one of the following forms of identification:(be sure to note which type of ID is used on form)Driver’ LicenseState issued ID cardPassport,Permanent Resident CardID Number specific to the IDState and Country where ID was issuedExpiration Date of ID provided
7 (All field with asterisks (*) are Mandatory!) Business Information(All field with asterisks (*) are Mandatory!)Applicant addresssPhone Number with extensionCity, State, Zip CodeManager’sManager’s phone number and extensionBusiness FULL NameNot just the corporate identifier, the complete facility nameApplicant Job TitleBusiness Physical address (must match facility name listed above)Applicant Manager’s NameManager’s Job Title
8 Required Signatures and Notary Involvement (All field with asterisks (*) are Mandatory!)Applicant and ManagerApplicant Signature and dateManagers Signature and date (NOTE: Manager must sign page 2 also)Notarization of Applicants’ IdentityNotary Signature DateNotary Seal/StampNotary expiration date (DO NOT LEAVE BLANK: use “None” or “At Death” if Notary Certification does not expire)Notary Signature
9 Selecting CW Roles and Scope (All field with asterisks (*) are Mandatory!)Select “Dialysis Facility” columnMedicare Provider Number: must match the Business name and address put on page 1. Medicare Provider (CNN)numbers start with:AR=04, LA=19, OK=37 (Do Not use Internal Corporate Number)ESRD Network Affiliation is 13For SA must select “Facility Administrator” roleOther Roles may also be selected (Discuss with your manager)
10 Additional Scope for Multiple Facilities (All field with asterisks (*) are Mandatory!)Use this section only if you work at multiple facilities and need access to edit or view data in CROWNWeb at those facilities. (NOTE: include only NW 13 Facilities on this form)NOTE: You can only be the SA for ONE facility: for additional facilities you can only select the Edit and/or View roles.Make sure your manager signs and dates this page(as well as page 1.)
11 FINAL STEPSThe applicant for SA will send their completed and notarized QIPS forms to Network 13, certified and return receipt requested, via US Mail to the following address:ESRD Network 13Attn: Sean Rosales4200 Perimeter Center Drive Suite 102Oklahoma, OKNETWORK 13 QIPS Contacts:Sean Rosales :Cindy Smith:Nellie Hedrick:
12 What Happens Next?The Network SA will enter the form into the QIPS system:If missing information, the Network SA will contact the applicant to obtain information .If information is incorrect or missing information is original signature and/or notarization, the Network SA will notify the applicant that a new form is required.If form is complete, it will be submitted via the QIPS system. A system generated from QIPS will be automatically sent to the applicant, the manager and the Network SA.The form will then be sent from the Network , certified and return receipt requested, to CMS Contractor via USPS to the CROWN HelpDesk for activation.The volume of forms at the Helpdesk determines the time needed for activation.