Quality Payment Program Support Request Form - North Carolina

We are ready to assist you with the Quality Payment Program reporting. 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. 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, PT, OT, SLP, CCC-A, RD, Psychologist, 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. Extension

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* 4. Email address

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* 5. Alternate Email Address

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* 6. Provide information about your practice. Note: QPP-eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, physical therapists, occupational therapists, speech-language pathologists, audiologists, psychologists 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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* 7. Is your TIN part of an ACO?

Yes

Unsure

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* 8. Is your TIN part of a MIPS APM?

Yes

Unsure

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* 9. 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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* 10. EHR Name and Version

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* 11. 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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* 12. Have you conducted a Quality Improvement initiative within the last 12-24 months in your practice? Examples include advance care planning, training on opiod prescribing guidelines for chronic pain, diabetes screening, or comprehensive eye exams.

Yes

Not sure

20% of survey complete.