To enroll in any/all of the following AHA/ASA programs, please complete the registration information, review the Unified Participation Agreement, and complete the electronic signature process below.
Select Which Programs/Permissions to ADD or CHANGE ENROLLMENT:This determines which information needs to be filled out and helps estimate pricing.
When making CHANGES to existing Stroke or Heart Failure Programs, your new "Unified Program Agreement" will be with the AHA/ASA. This agreement will cover all GWTG programs in which you are enrolled. If your agreement was previously with Quintiles for one or both of the Stroke and Heart Failure programs, you will get a termination notice from Quintiles - as your agreement is now directly with AHA/ASA. Quintiles will remain the PMT service provider and your invoices will still come from Quintiles.
GENERAL REGISTRATION INFORMATION
Hospital Address"Principal Office Location"
GENERAL HOSPITAL/FACILITY INFORMATION
Get With The Guidelines® (GWTG) - STROKE
Program Information / Requirements
Information used for placement in benchmarking groups for aggregate comparison reporting purposes.
Program Contact for GWTG-Stroke
Get With The Guidelines® (GWTG) - HEART FAILURE
Get With The Guidelines®-Heart Failure is an in-hospital program for improving care by promoting consistent adherence to the latest scientific treatment guidelines. Numerous published studies demonstrate the program's success in achieving significant patient outcome improvements. Among the proven results are reductions in 30-day readmissions, a measure now used by CMS in determining CMS reimbursement rates.
Program Contact for GWTG-Heart Failure
Get With The Guidelines® (GWTG) - RESUSCITATION
Get With The Guidelines®-Resuscitation .
Program Contact for GWTG-Resuscitation
Get With The Guidelines® (GWTG) - AFIB
Get With The Guidelines®-AFIB supports hospitals in many ways, including:
Data collection and feedback reporting are performed using the American Heart Association’s Patient Management Tool™ (PMT), an online, interactive system provided by Quintiles Real World & Late Phase Research.
Program Contact for GWTG-AFib
SELECT PACKAGES AND OPTIONS (PRICING)
Hospital shall pay an annual program fee per module ("Annual Fee") to Quintiles. 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 Quintiles $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"). In the event that the Initial Term is for a period of less than one (1) year, then Hospital shall pay a prorated portion of the Annual Fees (for example, if the Initial Term commences on November 1st, then Hospital shall pay 2/12 of the Annual Fees for 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.
Quintiles shall invoice Hospital annually and Hospital shall pay such invoice within thirty (30) days of receipt. All payments made for the Get With The Guidelines annual subscription fee and additional options are paid directly to QuintilesIMS.
ANNUAL COST ESTIMATE:
This is an ESTIMATE ONLY. The actual cost will be determined when Quintiles verifies existing program participation for multi-program discounts and prorates against annual cost are applied based on program start date.
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.
Hospital Address(Will be used for showing on Map)
To give American Heart Association/American Stroke Association (AHA/ASA) permission to use our name for:
STATE OR HEALTH SYSTEM INITIATIVES
Identify the State or Health System initiative in which you want to participate. If you plan to participate in more than one initiative, then select the "I want to select more than one initiative" option. You will be contacted with additional steps to complete your registration with these initiatives.
PARTICIPATION AGREEMENT and ACCEPTANCE
UNIFIED PARTICIPATION AGREEMENT
Downloadable pdf for offline review (UPA & DUA combined).Actual submissions must be via this electronic form.
DATA USE AGREEMENT
ELECTRONIC SIGNATURE of Hospital Representative