Quality Payment Program Eligibility Confirmation

Quality Payment Program Eligibility Confirmation
Please complete this form to confirm your eligibility for participation in the Quality Payment Program. All information will be used to assess your qualification.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization/Practice Name
Practice Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
National Provider Identifier (NPI)
The Last 4 Digits of Your Tax ID
Practice Type
Are you currently participating in the Quality Payment Program?
Select all eligibility criteria that apply to your practice:
Other
Please provide any additional comments or notes regarding your eligibility.
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