Clinigence 2019 TPF Member Renewal Form
This form is for current TPF customers to renew service through Clinigence Health. As a member of The PPRNet Foundation, all renewals are automatically enrolled in all of the 2019 PPRNet program measures.
Email address *
Your answer
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
Do you need Clinigence to submit MIPS for 2019? *
If you elect to have Clinigence submit MIPS data on your behalf, note the following (otherwise you can ignore).
Yes
No
N/A
Quality
Promoting Interoperability
Improvement Activities
If you elect to have Clinigence submit MIPS data on your behalf, 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.
Note that the following measures are NOT available for selection this year (2019) for MIPS submission:

• Diabetes Foot exam (CMS123v6)
• IVD : Use of Aspirin or Antiplatelet (CMS164v6)
Are you submitting MIPS 2019 as a Group or Individual? *
Practice/Provider TIN *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Participating Providers *
List the providers who will be participating in the program. Include the provider name and specialty.
Your answer
Additional Information
Include anything else we should know about the practice.
Your answer
Before Submitting this form:
If the practice is participating in MIPS as individuals, each provider will need to complete and sign this consent form:
https://docs.google.com/forms/d/e/1FAIpQLSdZnZ5TRjRFEEW6xdkc7crmHVbaFWiGuQnMWzUobyVBDEJZyw/viewform

If the practice is participating in MIPS as a group, the group's security officer should complete and sign one consent form:
https://docs.google.com/forms/d/e/1FAIpQLScqY_3ybH-MqI1cATPTK2FdXIRfIB4phI0FECzY-1kjME22Gg/viewform
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