Agent (Vendor) Authorization Forms
The Ambulatory Surgical Center Quality Reporting (ASCQR) Program permits ASC facilities to authorize a third-party agent (Vendor, Billing Company, etc.) to submit QualityNet web-based measure data on behalf of their facility. In order to complete the authorization/de-authorization process, ASCs must complete and sign the appropriate ASC Agent form.
For detailed instructions on how to complete this process access the ASC Agent Authorization Instructions.
- ASC Agent Authorization Form — To authorize a third-party agent
- ASC Agent Change/Withdraw Authorization Form — To change or withdraw a third-party agent
To authorize, change, or de-authorize an agent, an ASC must complete the corresponding ASC Agent Authorization or an ASC Agent Change/Withdraw Form at least one month prior to the data submission deadline (currently May 15) applicable to the next payment year.
ASCs are responsible for the data submitted or for the lack of data submitted for their facilities, regardless of whether ASCs or authorized agents submit their data.
The ASCQR Program has made interactive resources available to assist Agents with the batch submission file and submission of this file. ASCs are responsible for the data submitted or for the lack of data submitted for their facilities, regardless of whether ASCs or authorized agents submit their data.
- WBM Batch Submission Interactive Tool (XLSM) – EFFECTIVE FOR ENCOUNTERS IN 2018 REPORTED MAY 15, 2019. This is an interactive spreadsheet, designed to allow Agents to become familiar with the batch submission file structure and contents. Agents are also able to put real data into the spreadsheet, run checks for common errors, and export the data directly into a CSV file for upload to the QualityNet External Files Online Tool.
NOTE: This file does produce a security warning because of it’s interactive content. MD5 Checksum for file integrity: 9d634b8bd811458725423b476ee52f30
- WBM Batch Submission Instructions (PDF) – Instructions for the interactive spreadsheet.
Please note that ASC-8 is not submitted through QualityNet and therefore is not eligible for the ASC Agent Authorization.