MDinteractive PQRS/eRx Consent form MDinteractive
pandre@mdinteractive.com
800-634-4731 (phone)
866-251-4069 (fax)

Participation in Physician Quality Reporting System (PQRS) and/or Electronic Prescribing (eRx) Incentive Program

I give MDinteractive Registry permission to submit data to the Centers for Medicare & Medicaid Services (CMS) on my behalf to be used in the PQRS and/or eRx programs.
I understand that entering an incorrect individual NPI or an incorrect taxpayer identification number (TIN) will result in the loss of the PQRS and/or eRX bonus.

Instructions for using the online signature box: Place the cursor inside the signature box. Depress the left mouse button at the point where you would like to begin drawing your signature. Hold the left mouse button depressed while you draw. Release the mouse button between words. Use the entire area of the signature box. The signature will be reduced in size to fit the document.

When you are satisfied with the signature, click the "Submit Agreement" button in order to send this document to MDinteractive.


Hold down the left mouse button to sign in the box below