MDinteractive MIPS Consent form MDinteractive
800-634-4731 (phone)
866-251-4069 (fax)

Participation in Merit-Based Incentive Payment System (MIPS)

I give MDinteractive Registry permission to submit data to the Centers for Medicare & Medicaid Services (CMS) to be used in the MIPS program.
I understand that entering an incorrect taxpayer identification number (TIN) may result in a MIPS penalty.

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