CMSS Licensing Contract

I attest that I, , am eligible to sit for the Medical Scribe Certification & Aptitude Test (MSCAT™) Examination to earn and become a federally licensed Certified Medical Scribe Specialist.

  I have met the clinical requirements.
Individual Licensee:
Name:
Address:
City: State: Zip:
Email: Phone:

Name of Doctor Licensed for:
Name of Practice, Hospital, or Entity Scribing for:
Phone: Email:

By e-Signing below, I confirm that the information is true and correct. I understand I will be federally licensed as a Certified Medical Scribe Specialist and issued 12-months federally compliant credentials, in compliance with Centers for Medicare & Medicaid Services (CMS), earning the CMSS™ designation. I understand I must keep my professional fees and CMSS™ licensure current at all times for my job and pay all required fees of the CMSS™ license annually. I understand to enter clinical documentation into Certified Electronic Health Record Technology (CEHRT), I understand I must be licensed to perform any clinical job functions, duties, and documentation entry into the Electronic Health Record (EHR), protecting both myself and the patients I will care for. I will keep my professional fees and CMSS™ licensure current and up to date, paying all annual licensing fees. I understand any forfeiture in paying my annual licensing fees will result in lapsed license and credentials, and will result in my account being sent to collections. I will also be required to purchase a new license. I will be required at that time to retake the MSCAT™ Licensing Examination again.

I understand it is my responsibility and will keep my account current and up to date at all times. I will keep my credit card up to date and on file. Any changes to required card on file, I will immediately update and inform the agency of any updates. I understand that any lapse or gaps in my card on file will result in my account being sent to collections, at which time I must bring current. I acknowledge and attest that I understand the requirements, I will be responsible for all fees incurred, and by clicking Agree, I am bound to the terms and conditions of all CMSS™ licensing requirements. I acknowledge this is a federally granted CMSS™ licensing contract, and I am ready to proceed with the roles, responsibilities, and requirements of carrying this license.

By clicking the ‘I Accept’ button, I acknowledge the ACMSS™ CMSS Licensing | Relicensing Terms & Conditions. I understand I cannot reproduce, share, duplicate, or otherwise copy or falsify information either in print or reproduce published documents. I acknowledge my electronic signature is equivalent to my manual signature signed, as defined by the Electronic Signatures in Global and National Commerce Act.

 

Signed: Date:
Printed Name:

I understand, I agree, and acknowledge I am bound to the ACMSS™ CMSS Licensing | Relicensing Terms & Conditions