Final Attestation Form - MIPS 2021

Prior to completing the 2021 MIPS Submission Attestation Form, be sure that you have reviewed your Final 2021 MIPS Submission Report. Refer to the Report Review article for more information.

Once you have completed your review of your Final 2021 MIPS Submission Report you will then need to complete the attestation form to certify your intent for Keet Outcomes QCDR to report your 2021 MIPS data to CMS.

*If you are reporting MIPS data for multiple Tax Identification Numbers (TINs) then a separate 2021 MIPS Submission Attestation Form will need to be completed for each distinct TIN.


Attestation Form

1. On the first page of the Attestation Form, complete the following fields:

Keet Organization Name: Utilize the Organization Name listed within the Final Report Release email you received

Organization Tax Identification Number (TIN): The TIN you enter should match the TIN listed in the Final Submission Report dashboard

Reporting Type: Select an option from the dropdown. This will be your Final Selection of how Keet Outcomes QCDR will report your 2021 data to CMS
For additional information regarding your options for reporting please review the Reporting Type Selection article.


2. Click Next

3. Based on the reporting type you selected from the dropdown, you will be brought to a second page where you will be asked to confirm the information you are submitting. Click on a tab below to view what the second page of the Attestation form will look like based on the reporting type selected. 

Group or Both Individual Not Reporting Voluntary