Completing Facility Security Administrator QualityNet Identity Provisioning System (QIPS) Registration Form

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 users reset passwords disabling users Submit user forms for activation An 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.

Getting Started Where to get the QIPS form: https://www.qualitynet.org/crown/registration_form.pdf

Completing the form Requests, Roles, and Dates Type of Request Check Create new user account QIPS Role Check the Security Administrator Date Request The QIPS/ID section is for existing users only (leave blank)

Personal Information Section Things that need to be completed: (All field with asterisks *) First and Last Name Personal address, City, State, Zip Code Birth date Fields without asterisks are optional.

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’ License State issued ID card Passport, Permanent Resident Card ID Number specific to the ID State and Country where ID was issued Expiration Date of ID provided

(All field with asterisks (*) are Mandatory!) Business Information (All field with asterisks (*) are Mandatory!) Applicant email addresss Phone Number with extension City, State, Zip Code Manager’s Email Manager’s phone number and extension Business FULL Name Not just the corporate identifier, the complete facility name Applicant Job Title Business Physical address (must match facility name listed above) Applicant Manager’s Name Manager’s Job Title

Required Signatures and Notary Involvement (All field with asterisks (*) are Mandatory!) Applicant and Manager Applicant Signature and date Managers Signature and date (NOTE: Manager must sign page 2 also) Notarization of Applicants’ Identity Notary Signature Date Notary Seal/Stamp Notary expiration date (DO NOT LEAVE BLANK: use “None” or “At Death” if Notary Certification does not expire) Notary Signature

Selecting CW Roles and Scope (All field with asterisks (*) are Mandatory!) Select “Dialysis Facility” column Medicare 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 13 For SA must select “Facility Administrator” role Other Roles may also be selected (Discuss with your manager)

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.)

FINAL STEPS The 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 13 Attn: Sean Rosales 4200 Perimeter Center Drive Suite 102 Oklahoma, OK 73112-2314 NETWORK 13 QIPS Contacts: Sean Rosales : 405.948.2259 Cindy Smith: 405.948.2240 Nellie Hedrick: 405.948.2253

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 email 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.