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

Completing QualityNet Identity
Provisioning System (QIPS) Registration
Form for User Editors and Viewers
Getting Started
Where to get the QIPS form:
Completing the form
Requests, Roles, and Dates
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Type of Request
 Check Create new user account
QIPS Role
 Check the QIPS Regular User
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
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
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
 Select “Facility Editor” (for user who will need to be able to enter and submit data)
 Select “Facility Viewer” (for user who will need only to be able to view data)
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)
 Make sure your manager signs and dates this page(as well as page 1.)
FINAL STEPS
The QIPS registration form for Editors and Viewers will be
entered into the QIPS system by the Facility SA, who will, after
entry, send the completed and notarized QIPS forms and
paperwork tag, certified and return receipt requested, via
US Mail to the following address:
CROWN QIPS Processing/CSC
PO Box 12238
Durham, NC 27709
For additional assistance in completing the QIPS registration form:
NETWORK 13 QIPS Contacts:
Sean Rosales : 405.948.2259
Cindy Smith:
405.948.2240
Nellie Hedrick: 405.948.2253