Please send me a proposal for the PPRNet CQM program

Name

First Last

Email*

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Practice Legal Name*

Address*

Street Address Address Line 2 City State ZIP Code

What EHR are you using?*

If you are not using Practice Partner, please specify the name and version of your EHR

Practice Partner Version Number*

Have you purchased Practice Partner EHR through a Value-Added-Reseller (VAR)?*

Name of VAR:*

How many providers in your practice?*

Do you need to submit MIPS for the current program year?*

Are you submitting MIPS as a group or individually?*

Are you interested in other CQM programs in addition to PPRNet/MIPS?

Are all providers in your practice members of TPF?*

How many TPF members in your practice?*

Please provide contact info for your IT person*

First Last

Who would you like us to contact to coordinate the implementation?

IT Contact Phone

IT Contact Email

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