Clinigence 2019 MIPS Quality and Improvement Activity Enrollment Form
Use this form to select the measures associated with the Quality section and the activities associated with the Improvement Activities section of the 2019 MIPS program. Note that the following measures are NOT available for selection this year when using the EHR Reporting mechanism:

• Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use CMS169v6
• Diabetes Foot exam CMS123v6
• Diabetic Macular Edema CMS167v6
• Hypertension : Improvement in Blood Pressure CMS65v7
• IVD : Use of Aspirin or Antiplatelet CMS164v6
• Pregnant Women that had HBsAg testing CMS158v6

Measure Selection: Practices must select at least 6 measures and up to 12 measures to be shared across all providers in the practice. You must select at least 1 high priority or 1 outcome measure.
• Additional measures can be purchased at the time of the order or after the initial implementation for $200 per measure. Note that this is a per measure fee, not a per provider fee.
• Once the original measure order is implemented any "swapping" of measures will be treated as an additional measure and will incur a $200 per measure fee.

Measure Submission: Clinigence will submit all measures for all participating providers in the practice or the Group. CMS will use the 6 most advantageous to each provider or Group.
Email address *
Clinigence Partner Name *
The name of the Clinigence partner from whom this service is being purchased If you are purchasing the service directly from Clinigence type "Clinigence".
Your answer
Your Name *
Your answer
Your Phone Number *
Your answer
Practice Name *
Your answer
Did Clinigence submit MIPS for this practice in 2018? *
Do you intend to report as a group or as individual providers? *
Practice TIN *
The TIN used to file Medicare PartB claims.
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number
Only required for new sites.
Your answer
Practice Type
Only required for new sites. For example: Family Medicine, Pediatrics, General Surgery, Cardiology, etc.
Your answer
Participating Providers *
List the providers who will be participating in the program. Include the provider name and specialty.
Your answer
EHR Name and Version Number
Only required for new sites.
Your answer
Practice Technical Contact
Only required for new sites and Clinigence is doing the installation. Include the name, phone, and email information for this person who can provide Clinigence with EHR server access.
Your answer
Medicare Carrier Codes *
What IDs do you use in your EMR to identify patients as having Medicare Part B, Secondary, or Railroad coverage? For example, MED01, MED00, Medicare. Do NOT include IDs for other Medicare plans such as Medicare Advantage. If you are a new customer or have changed the codes since last year list the codes in the text area after selecting Other. Likewise, if this information is not in your EMR but in a different system please indicate this in the free text area after selecting Other.
Estimated Number of Medicare Patients in 2019
An approximate number of unique Medicare (Part B, Secondary and RR) who will have been seen in 2019. This can be based on your 2018 numbers if you expect them to be about the same. We use this count to ensure that we are finding all of your Medicare patients based on the Medicare carrier codes you have provided.
Your answer
Additional Information
Include anything else we should know about your selections. For example, if selecting more than the allotted number of base package measures please indicate the number of additional measures you are approving.
Your answer
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