Clinician Consent

2021 Clinician Consent

This Consent Form is between AASM and the below named Eligible Clinician. The AASM is required to obtain a copy of this Consent Form from all Eligible Clinicians whose quality data will be submitted to the Centers for Medicare and Medicaid Services (“CMS”).

The Eligible Clinician hereby represents and warrants to AASM the following:

  1.  The Eligible Clinician is eligible to submit quality data to CMS in connection with the Merit Based Incentive Payment System (MIPS) program.
  2. The Eligible Clinician voluntarily consents to the submission of data on behalf of the Eligible Clinician to CMS.
  3. The Eligible Clinician grants permission to AASM to provide CMS with copies of this Consent Form and any required patient level or other data requested by CMS to comply with CMS guidelines.

The Eligible Clinician understands and agrees that this Consent Form shall remain in full force and effect unless written notice of termination is provided to AASM.

Name of Eligible Clinician:

Signature of Eligible Clinician:

Dated:

Address:

Telephone:

Individual NPI No:

TIN No:

AASM MUST MAINTAIN SIGNED COPIES OF EACH ELIGIBLE CLINICIAN CONSENT FORM FOR SEVEN YEARS. FORMS MAY BE AUDITED BY CMS.