Merit-Based Incentive Payment System (MIPS) Reporting
Clinician Registration Consent - SIGNATURE REQUIRED
In consideration of participation in the Merit-Based Incentive Payment System (MIPS) administered by the U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services ("CMS"), Envision Physician Services has contracted and agreed to use various Qualified Clinical Data Registries (QCDRs) by lines of business/specialties as well as direct claims based reporting as required for MIPS-eligible providers under MACRA, if QCDR reporting options are unavailable.
I hereby acknowledge, authorize and agree to the following:
- Envision Physician Services is authorized to submit quality measure results, improvement activities measure and activity results, advancing care information objective results and numerator and denominator data or patient-specific data on Medicare and non-Medicare beneficiaries to CMS on my behalf in a manner that complies with all applicable laws, regulations and CMS guidelines now and in the future, for the purpose of MIPS participation;
- I will cooperate and comply with all requests from Envision Physician Services as needed to accomplish the timely collection and submission of the above-referenced data in order to ensure that I continue to qualify for the Medicare clinician incentive payment program or to avoid payment adjustments, and understand this Consent shall remain in full force and effect unless I provide Envision Physician Services written notice of termination;
- By checking the below box and clicking “submit,” I hereby indicate my agreement to the above conditions and understand it is equivalent to an electronic signature.
Not you? Please clear your Internet browser cookies, then click the link in the email again. If the form is still incorrect, contact us.