EHealth Made Easy | Letter of Authorization

Free PQRI Registry eHealth Made EASY LLC Letter of Authorization I, the undersigned, hereby authorize eHealth Made EASY LLC ("eHealth") to collect, analyze, store, and submit to the Centers for Medicare and Medicaid Services ("CMS") quality measure codes and related data ("Quality Data") that I submit to eHealth for purposes of my participation in the CMS Physician Quality Reporting Initiative program ("PQRI Program"). I understand that eHealth cannot submit Quality Data for the PQRI Program to CMS on my behalf unless I sign this Letter of Authorization. I understand that CMS requires that the Quality Data be submitted under my individual National Provider Identifier ("NPI") and my Taxpayer Identification Number ("TIN"), and I hereby authorize eHealth to release my NPI and TIN along with my Quality Data to CMS. I understand that I am responsible for ensuring that (a) I file my CMS Part B Fee For Service (FFS) claims in a timely manner so as to be processed by CMS by February 26, 2010, and (b) I identify my individual NPI on my claims. I understand that I may not receive a PQRI payment if I fail to comply with the above requirements. I represent that the Quality Data that I report will be complete and accurate. I agree to hold eHealth, its officers, directors, and representatives harmless against any claims or losses resulting from eHealth's reliance on this Letter of Authorization. In accordance with CMS requirements for the PQRI program, I understand that eHealth is required to conduct random sample audits of its users. I hereby consent to be audited by eHealth upon its request and to cooperate with eHealth's auditing process. The CMS mandated auditing process may include granting eHealth representatives access to claims, chart data and other material related to the information submitted to CMS for a PQRI bonus payment as eHealth reasonably requests. This Agreement is governed by the laws of the State of New York applicable to agreements wholly made and performed there. _____________________________ _____________________________ Provider Signature Date _____________________________ _____________________________ Provider Name _____________________________ _____________________________ _____________________________ Provider Address Provider NPI For CMS Part B FFS Claims _____________________________ Provider TIN Please return this completed form via FAX to 1.877.394.7774 or email a .pdf copy to support@ehealthmadeeasy.com. 3399018v.3 3399018v.5 Get Adobe Flash player