Additional Guidance on Information Needed in Exceptions Requests to Display Hospital or ASC Name and/or Logo on Outgoing Envelopes
folder_openSurvey Specifications and Guidelinescalendar_todayPosted March 6, 2018

CMS and the OAS CAHPS Survey Coordination Team are issuing additional guidance about what information needs to be included in the Exceptions Requests required to print hospital and ASC names and/or logos on outgoing mailing envelopes.

To display an outpatient facility’s name and/or logo on an outgoing mailing envelope, vendors must obtain the facility’s permission to display the name and/or logo and assurances that the facility does not consider displaying the name and/or logo to be a HIPAA risk. It is up to each vendor to determine what kind of documentation or assurances it needs from its clients for its own internal recordkeeping to feel comfortable submitting the Exceptions Request Form (ERF). The Coordination Team will not review any documentation pertaining to this ERF during oversight visits.

The ERF submitted to the Coordination Team should include a statement that the vendor has discussed or will discuss the potential for HIPAA risks with its current and future client(s) and has or will obtain approval from the client(s) to display the facility name and/or logo on the envelope or through the envelope window. Vendors only need to submit one ERF to cover all their current and future clients. 

Please contact the Coordination Team via e-mail at oascahps@rti.org or call toll-free (866) 590-7468, if you have any questions.