Transcript Setting Up Your Facility’s Security Administrators (SA)

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:
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)
o
o
o
o
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
Business Information
(All field with asterisks (*) are Mandatory!)
 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
 Applicant email addresss
 Phone Number with extension
 City, State, Zip Code
 Manager’s Email
 Manager’s phone number and
extension
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.