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MIPS Second Opinion
PRACTICE INFORMATION
Practice Group/Name
*
Website
Primary Contact Name
*
Title/Role
*
Contact Phone
*
Contact Email
*
State(s) of Operation
*
PRACTICE STRUCTURE & COMPOSITION
Number of TINs
*
Total Clinicians (NPIs)
*
Scope of Practice/Specialty
Dermatology
Behavioral Health
Primary Care
Multi-specialty
Other
HEALTH IT REPORTING & INFRASTRUCTURE
Current EHR Vendor
*
Previous EHR Vendor (if applicable)
Planned Future EHR (if applicable)
Current Registry/QCDR (if applicable)
Current Method for Quality Data Acquisition
EHR direct (eCQM)
Registry/QCDR
Manual extraction/claims
Other
MIPS PERFORMANCE HISTORY
Submission Method
Individual
Group
Virtual Group
MVP
APM
Most Recent MIPS Final Score
Most Recent Category Scores (if known)
Quality (score out of 30)
PI (score out of 25)
IA (score out of 15)
Cost (score out of 30)
PI Hardship Exception
Past or Current Quality Measures Utilized
Quality Measure 1
*
Quality Measure 2
*
Quality Measure 3
*
Quality Measure 4
*
Quality Measure 5
*
Quality Measure 6
*
Prior MIPS Assistance
EHR vendor support
Registry/QCDR vendor
External consultant
Internal staff only
None
CHALLENGES & GOALS
Concerns, past struggles, expectations
Additional Notes
Submit
