MDinteractive Consent form
CMS Quality Programs and Initiatives Participation
I give MDinteractive permission to submit data to the Centers for Medicare & Medicaid Services (CMS) to be used in CMS Quality Programs and Initiatives, including Merit-Based Incentive Payment System (MIPS), Primary Care First (PCF), APM Performance Pathway (APP) and other such programs as CMS should institute from time to time.
I authorize MDinteractive to submit Quality measure results, Improvement Activities measure and activity results, Promoting Interoperability measure and objective results and numerator and denominator data or patient-specific data on Medicare and non-Medicare beneficiaries to CMS for the purpose of participation in MIPS or other CMS Quality Programs and Initiatives.
I acknowledge that I am responsible for providing the correct taxpayer identification number (TIN) and understand that entering an incorrect TIN may result in a financial penalty per CMS Program and Initiative rules.
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