Register for User Account

All individuals must complete the on-line user registration form to obtain an account. The form must be signed and e-mailed to the address listed on the registration form. Your account is activated after the form is received and approved by MassQEX.

User Registration Form

Note: fields marked with an * are required information.

User Information

* First Name
Middle Initial
* Last Name
* Job Title
* Organization
* Organization Type	Please select... Vendor Provider
Vendor Name
Medicare Inpatient Provider ID
MassHealth Inpatient Provider ID
* Hospital Program	Please select... Clinical Quality Incentive (CQI) Program Hospital Quality and Equity Incentive Program (HQEIP) Both CQI and HQEIP
* Address 1
Address 2
* City
* State	Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
* Zip Code
* Phone Number
Extension
* Fax Number
* E-Mail Address

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