Important: Note that the 2019 MIPS program consists of multiple scoring categories. This consent form represents one of those scoring categories, the Quality section.
Instructions 1) Complete all the fields except the signature and date lines. Do not submit the form yet! 2) Print the form before submitting. 3) Submit the form. Once submitted, a copy of your form responses will be emailed to the email address included in the form. 4) If you are submitting forms for multiple TINs, repeat steps 1 through 3 until you have finished. 5) Have the Group Security Officer sign and date the printed form(s). 6) Scan and email the signed form(s) to email@example.com.
Group Security Officer Signature: _________________________________________________