MIPS Intake Form

ChiroTouch provides an intake guideline as a courtesy. You can provide this basic intake form to your patients to collect all of the information needed to meet Promoting Interoperability (formerly ACI) compliance.

Be advised you can create your own intake form as long as it includes the following requirements:

• Providers Name and Office Contact Information (automatically applied through ChiroTouch)
• Patient's Full name (automatically applied through ChiroTouch)
• Current Medication History
• Current Allergy information
• Smoking Status
•  Vital Signs
  • Height
  • Weight
  • Blood pressure

• Demographic Information
  • Preferred Language
  • Sex
  • Race
  • Ethnicity
  • Date of Birth

Because you are required to allow the patient access to their current health information you must provide the patient with this form at least once per year, this should be done on the initial visit at the beginning of the reporting period. Enter all updated information into your system and leave all unchanged information as is.

Because most of this information may have been collected in previous reporting periods for your existing patients, there is no need for those patients to fill it out again, unless something has changed. You should focus on your new patients that come in during each reporting period to make sure you are able to stay compliant with MIPS requirements for all of your patients seen during the reporting period.

Click on the document icon above to download the EHR Intake Form. The information listed on this form reflects the most current Prompting Interoperability (Formerly Advancing Care Information) requirements for 2018 reporting.