Practice

Request MIPS Assistance

Request MIPS Assistance

Data Submission Image 1

Data Submission Image 2

HSAG provides no-cost technical assistance to help you navigate and implement the QPP.
Please complete the form below so we can best assist you in these efforts.

* Indicates a required field

Please enter your 9 digit Tax Id Number (TIN) to begin registration

TIN *

Practice Name *

I would like to receive email notifications for future events

Practice Phone *

Practice Fax Number

Primary Contact First Name *

Primary Contact Last Name *

Primary Contact Title

Primary Contact Phone

Ext

Other Primary Contact Title

Primary Contact Email *

Confirm Primary Contact Email *

Address 1 *

Address 2

City *

State *

ZIP Code *

QPP Participation Intention

QPP Path Required.

Reason for not participating in MIPS Required.

Other reason not participating in MIPS Required.

Intended Data Submission Method: Quality

Intended Data Submission Method: PI

Intended Data Submission Method: IA

QCDR Qualified Registry Options

MIPS Participation Required.

Clinician:Name

NPI

Specialty

{{practiceAssessmentClinician.clinicianName}}

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{{practiceAssessmentClinician.clinicianSpecialty}}

MIPS performance categories where you need help

No help needed

Some help needed

We don't know where to start

Improvement Activities

1

2

3

4

5

Quality

1

2

3

4

5

Promoting Interoperability

1

2

3

4

5

Cost

1

2

3

4

5

Do you have an Electronic Health Record (EHR) system?

Yes

No

EHR Product Name EHR Product Name is required.

EHR Version EHR Version is required.

Other EHR Product Name EHR Name is required.

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