Data Delivery Ts&Cs for Registry Reporting

Data Delivery

(See Data Delivery section to this Order Form for additional terms and conditions)

Legal Practice Name *

EMA URL(s) *

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Did you have a support case open regarding Data Delivery? *

What is your support case number? *

Do you plan on reporting your MIPS Quality data to a 3rd party registry? *

Which 3rd party registry are you planning on using? *

The Modernizing Medicine Standard Terms and Conditions, located at https://www.modmed.com/terms-and-conditions_9_22/ apply to this Order Form, and are incorporated herein by reference.