MIPS DATA RELEASE AND SUBMISSION CONSENT FORM

I give Persivia, Inc. (“Persivia”) permission to submit data to the Centers for Medicare & Medicaid Services (CMS) to be used in the Merit-Based Incentive Payment System (MIPS), and/or Advanced Payment Model (APM), as required.

I authorize Persivia 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 and/or APM.

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.