AHA-ASA M:L Program Enrollment Form

Mission:Lifeline Program Enrollment
To enroll in the AHA/ASA Mission:Lifeline^® program, please complete the registration information, review the Unified Participation Agreement, and complete the electronic signature process below.
PROGRAM ACTION SELECTION
Mission Lifeline*

SECTION - GENERAL REGISTRATION INFORMATION
GENERAL REGISTRATION INFORMATION
Hospital (Legal) Name*
"Program Participant"
Hospital Address
"Principal Office Location"
Street 1*
Street 2
City*
State*
Zip Code*
MAIN Contact
Name*

First NameLast Name
Job Title*
Phone
Email*
BILLING Contact
Billing Contact

Same as Main Contact
Name*

First NameLast Name
Job Title*
Phone
Email*

SECTION - GENERAL HOSPITAL/FACILITY INFORMATION
GENERAL HOSPITAL/FACILITY INFORMATION
State*
In which state is your facility located?
Facility Type*
AHA Hospital #
American Hospital Association Number (7 digit #)
CCN – CMS Certification Number
Six-digit Medicare certification number (Provider Number)
PMT SiteID
Please provide, if already using Quintiles PMT system (5 digit #)
Is facility designated as a 'Critical Access Hospital'?*
Academic hospital?*
Is your hospital an Academic hospital (i.e., are residents involved in patient care)?
Total Bed Count*
What is the total number of BEDS in your Hospital?
Actual or Estimate*
Is the bed count Actual or Estimated?

SECTION - Mission: Lifeline®
Mission:Lifeline® Program

Program Summary

Mission:Lifeline® is the American Heart Association/American Stroke Association (AHA/ASA) collaborative performance improvement program, currently supporting Mission:Lifeline ACS and Stroke Systems of Care demonstrated to improved adherence to evidence-based care of patients hospitalized with time sensitive emergencies, such as STEMI, NSTEMI, and Stroke.

What are the benefits of participating in Mission:Lifeline®- program?
- Assess to the most up-to-date research and scientific publications
- Professional educational opportunities
- Clinical tools and resources
- Patient education resources
- American Heart Association, quality improvement field staff support with expertise in Systems of Care implementation and regionalization
- Participation in a regional systems of care task force
- National and local recognition for hospital team program achievement
- Participation qualifies hospitals for Mission:Lifeline STEMI Accreditation
- Performance feedback reporting for continuous quality improvement◦Feedback reports for participating hospitals
  - Feedback reports for participating hospitals to share with referring hospitals*
  - Feedback reports for participating hospitals to share with EMS agencies*
- Participation in regional feedback reports
  - Regional feedback reports used to guide Mission:Lifeline Implementation and Regionalization efforts*
- Third party access to data
  - State Department of Health
  - State Hospital Association
* Effective May 31, 2017.

What is the cost of Mission:Lifeline®?

The program is FREE for 2017! Special 2018 pricing expires November 1, 2018. Price increases for enrollments after that date. See the pricing sheet for the 2018 package options and pricing.

Required agreements for participation in Mission:Lifeline®?
- American Heart Association:
  - Signed Unified Program Agreement (including the BAA)
- Third Party Vendor
  - Program Participant must execute separate agreements with Third Party Vendor.
Data Submission Requirements

Program Participant will be responsible for submitting data to AHA Third Party Vendor through abstractions into technology platform, data upload, EHR, HIE, web services, or other identified data repository. Inpatient registries approved for Mission: Lifeline Submission include:
- Mission:Lifeline - Stroke
  - Get With The Guidelines- Stroke
- Mission:Lifeline - ACS
  - Get With The Guidelines- CAD
Data Set Descriptions and Requirements:

To conduct quality improvement and scientific research activities, the American Heart Association will require access to certain health information. Mission:Lifeline will require the below listed data elements be included:

Limited Data Set Requirements:
- Admission Date/Time
- Arrival Date/Time
- Sign/Symptom Onset Date/Time
- First Medical Contact Date/Time
- Discharge Date/Time
- Patient age
- Patient Age units
- Limited Data Set identifiers, as provided for in 45 C.F.R. §164.514(e)(2), may be included
Ownership and Access to Data:

Program Participants retain ownership Individually Identifiable Health Information and Limited Data Sets subject to the rights granted to the designated AHA Third Party Vendor and AHA in this Agreement and the BAA.
Program Benchmarking Information
AMI # Annually*
How many Acute Myocardial Infarctions does your hospital have per year?
Actual or Estimate*
Is the AMI number Actual or Estimated?
Cath Lab Status*
Status/Type of Catheterization Laboratory
Participation in M:L Regional Reports*
Participation in regional reports allows for a groupof 3 or more hospitals to be included in a comparison group. Requirements for inclusion of regionalreports are available in the Mission: Lifeline Program Summary.
Consent to Participate in an Unblinded Regional Report*
Information used for placement in benchmarking groups for aggregate comparison reporting purposes.
Program Contact for Mission:Lifeline^®
M:L Contact

Same as Main Contact
Name*

First NameLast Name
Job Title*
Phone
Email Address*

SECTION - PACKAGES, OPTIONS and PRICING
SELECT PACKAGES AND OPTIONS (PRICING)

Hospital shall pay an annual program fee per module ("Annual Fee") to The American Heart Association. The Annual Fee allows up to ten (10) users to access the system per module. For each additional user per year greater than ten (10), Hospital shall pay $99 per module per year ("Additional User Fees").

The Annual Fees listed below shall remain in effect from the date the Hospital accepts the electronic Unified Participation Agreement through December 31, 2018 (the "Initial Term"). After the Initial Term, the Agreement below shall automatically renew for additional periods of one (1) year, at the then-current annual fees, unless either party shall give the other party at least sixty (60) days prior written notice of termination.

The American Heart Association shall invoice Hospital annually and Hospital shall pay such invoice within thirty (30) days of receipt. All payments made for the GWTG-CAD annual subscription fee and additional options are paid directly to The American Heart Association.

Pricing Sheet
GWTG-CAD OPTIONS

2017 FREE! Early Adopter - get GWTG-CAD for FREE through 2017
GWTG-CAD PACKAGE for 2018*

GWTG-CAD with direct data entry into GWTGGWTG-CAD with authorized vendor data submissionGWTG-CAD with static quarterly reports
Authorized Vendor
If your hospital is choosing to use an Authorized Vendor, please list the name of the Authorized Vendor.

PERMISSION FORM - QUALITY IMPROVEMENT PROGRAMS
QUALITY IMPROVEMENT PROGRAMS PERMISSION FORM
This section allows you to give American Heart Association/American Stroke Association (AHA/ASA) permission to use your hospital name for recognition events, ads, conference banners, and on the AHA website. It allows you to indicate the exact (marketing) name you want used as well as the associated mapping location. This form is typically filled out once by the hospital - and updated only when changes are needed.
Programs Permission*
Hospital Recognition Name and agreement to be recognized
Hospital (Legal) Name*
My Hospital wishes to be recognized as:
Hospital name as it should appear in any recognition/promotional opportunity
Hospital Address
(Will be used for showing on Map)
Street 1*
Street 2
City*
State*
Zip Code*
We AgreeWe Do Not Agree
To give American Heart Association/American Stroke Association (AHA/ASA) permission to use our name for:
- Recognition Events
- Ads (may include: AHA’s Circulation; ASA’s Stroke; US News & World Report)
- Conference banners/signage
- AHA website, digital media, mobile apps
- The Joint Commission and other regulatory agency

SECTION - PARTICIPATION AGREEMENT and ACCEPTANCE
PARTICIPATION AGREEMENT and ACCEPTANCE
UNIFIED PARTICIPATION AGREEMENT
Downloadable pdf for offline review (UPA & BAA combined).
Actual submission must be via this electronic form.
BUSINESS ASSOCIATE AGREEMENT

SECTION - ELECTRONIC SIGNATURE
ELECTRONIC SIGNATURE of Hospital Representative
Name of Signer*

First NameLast Name
Title of Signer*
Email of Signer*
for copy of agreement
Hospital Tax ID*
Effective Dat*

MonthDayYear
Date
Submit Time Stamp

MonthDayYear
DateHourMinutes
Timer
Should be Empty:

Mission:Lifeline Program Enrollment