2019 MIPS Quality Individual Provider Consent Form

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By completing and signing this document the provider identified in the signature section below authorizes Clinigence, LLC an authorized EHR Data Submission Vendor and Qualified Registry, to submit on the provider's behalf aggregate and patient-specific data on all patients for the purpose of 2019 MIPS Quality participation. Upon request by CMS Clinigence may also submit information specific to the Medicare beneficiary population.

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 providers, repeat steps 1 through 3 until you have finished.
5) Have the provider(s) sign and date the printed form(s).
6) Scan and email the signed form(s) to support@clinigence.com.

Provider Signature: _______________________________________________________

Date: ________________________

Provider Name (printed) *

Practice Name *

Legal Business Name *

The name registered with your TIN. This may or may not be the same as your practice name.

Street Address *

City *

State *

Zip Code *

Provider TIN *

This is the 9 character TIN used by the provider to submit claims to CMS.

Provider NPI *

This is the 10 character individual provider NPI, not the practice NPI.

Submit

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