Spring Medical 2017 Medicaid Clinical Quality Measures
Use this form to select the measures associated with the Clinical Quality Measure section of the 2017 Medicaid program. Note that the following measure is NOT available for selection this year when using the EHR Reporting mechanism.

Use of Appropriate Medications for Asthma

Measure Selection: Practices must select a total of 9 measures to be shared across all providers in the practice.  In order to meet the CMS requirements when selecting measures, be sure to select at least 1 measure in at least 3 clinical quality domains.
Additional measures can be purchased the time of the order or after the initial implementation for $200 per measure. Note that this is a per measure fee, not a per provider fee.
Once the original measure order is implemented any "swapping" of measures will be treated as an additional measure and will incur a $200 per measure fee.

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Email *
Clinigence Partner Name *
The name of the Clinigence partner from whom this service is being purchased.  This form is for Spring Medical customers only.  Thus this field defaults to and should always be Spring Medical.
Your Name *
Your Phone Number *
Practice Name *
Did your practice use Clinigence for CQMs 2016? *
Street Address
Only required for new sites.
City
Only required for new sites.
State
Only required for new sites.
Zip Code
Only required for new sites.
Phone Number
Only required for new sites.
Practice Type
Only required for new sites.  For example: Family Medicine, Pediatrics, General Surgery, Cardiology, etc.
Participating Providers *
List the providers who will be participating in the program.  Include the provider name and specialty.
EHR Name and Version Number
Only required for new sites.  Because this form is only to be used by Spring Medical customers this value is defaulted to Spring Medical.
Practice Technical Contact
Only required for new sites and Clinigence is doing the installation.  Include the name, phone, and email information for this person who can provide Clinigence with EHR server access.
Additional Information
Include anything else we should know about your selections.  For example, if selecting more than the allotted number of base package measures please indicate the number of additional measures you are approving.
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