Alliant Quality Payment Program Support Request Form

Welcome to our support center! Please answer a few questions so we know how best to support you and your practice. You must answer questions #1 through #4 to provide us with your contact information. You may stop the survey any time after that and we'll contact you for assistance (you'll need to page through to the end in order to submit). The more information you give us, the better we'll be able to help.

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* 1. Please provide your contact information

Your first name

Your last name

What is your role in the practice? (MD, PA, NP, DO, CNS, CRNA, Practice Manager, other)

Best time of day to reach you between 8AM and 5PM

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* 2. Your phone number - provide number only - no dashes, spaces or parentheses.

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* 3. Your email address

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* 4. Provide information about your practice. Note: QPP-eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and groups that include such clinicians who bill under Medicare Part B.

Name of the Practice *

Tax ID Number for the Practice (9-digits)

City/Town *

State/Province *

Number of clinicians under the Tax ID number *

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* 5. Do you have an Electronic Health Record (EHR)?

Yes, ONC-certified EHR technology

Yes, not sure if it is ONC-certified EHR technology

Not sure if we have an EHR

We do not have an EHR

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* 6. What Stage of the Medicare EHR Incentive Program (Meaningful Use) is your practice in?

Completed 2016 Modified Stage 2

Participated before, but did not continue

Never participated

Not sure

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* 7. Are you a recognized medical home?

Yes - a Patient-Centered Medical Home (PCMH)

Yes - a Patient-Centered Specialty Practice (PCSP)

Not sure

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* 8. Have you conducted a Quality Improvement initiative in your practice? Examples include increasing mammography screening or increasing the number of patients with diabetes who receive an annual A1C test.

Yes

Not sure

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* 9. Has your practice successfully reported PQRS?

Yes

Not sure

20% of survey complete.