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 to enter clinical documentation into Certified Electronic Health Record Technology (CEHRT), I must be licensed to perform any clinical documentation entry into the Electronic Health Record (EHR). I agree I will keep my professional fees and CMSS licensure current with all fees paid annually. Any forfeiture in fees, will result in lapsed credentials and licensing, at which time I must purchase and retake the MSCAT™ Examination. 

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: