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Getting Started

Completing QualityNet Identity Provisioning System (QIPS) Registration Form for User Editors and Viewers. 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

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Getting Started

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  1. Completing QualityNet Identity Provisioning System (QIPS) Registration Form for User Editors and Viewers

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

  3. Completing the formRequests, Roles, and Dates • 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)

  4. 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.

  5. 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

  6. Business Information • 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

  7. 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

  8. 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)

  9. 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.)

  10. 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 13QIPS Contacts: • Sean Rosales : 405.948.2259 • Cindy Smith: 405.948.2240 • Nellie Hedrick: 405.948.2253

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