MIPS Coaching – 1st Program Year MIPS Coaching – 1st Program Year MIPS Coaching: 1st Program Year (2019) ChartMaker® Clinical (EMR)MIPS is all about your patient data which means you need to have ChartMaker® Clinical (EMR). If you do not currently have ChartMaker® Clinical (EMR), please indicate that by checking the box below. Please send me a quote for ChartMaker® Clinical (EMR) as I do not currently have it I agree to the following for Provider #1:*MIPS COACHING: $250 per month 1st Clinician, $125 for each additional clinician)Provider #1* First Last Credentials Provider #1 NPI*Provider #1 Email* Would you like to add another provider?YesNoI agree to the following for Provider #2:*MIPS COACHING: 1st Program Year ($250 per month 1st Clinician, $125 for each additional clinician)Provider #2 First Last Credentials Provider #2 NPIProvider #2 Email Would you like to add another provider?YesNoI agree to the following for Provider #3:*MIPS COACHING: 1st Program Year ($250 per month 1st Clinician, $125 for each additional clinician)Provider #3 First Last Credentials Provider #3 NPIProvider #3 Email Would you like to add another provider?YesNoI agree to the following for Provider #4:*MIPS COACHING: 1st Program Year ($250 per month 1st Clinician, $125 for each additional clinician)Provider #4 First Last Credentials Provider #4 NPIProvider #4 Email Would you like to add another provider?YesNoI agree to the following for Provider #5:*MIPS COACHING: 1st Program Year ($250 per month 1st Clinician, $125 for each additional clinician)Provider #5 First Last Credentials Provider #5 NPIProvider #5 Email Would you like to add another provider?YesNoI agree to the following for Provider #6:*MIPS COACHING: 1st Program Year ($250 per month 1st Clinician, $125 for each additional clinician)Provider #6 First Last Credentials Provider #6 NPIProvider #6 Email Would you like to add another provider?YesNoI agree to the following for Provider #7:*MIPS COACHING: 1st Program Year ($250 per month 1st Clinician, $125 for each additional clinician)Provider #7 First Last Credentials Provider #7 NPIProvider #7 Email Would you like to add another provider?YesNoI agree to the following for Provider #8:*MIPS COACHING: 1st Program Year ($250 per month 1st Clinician, $125 for each additional clinician)Provider #8 First Last Credentials Provider #8 NPIProvider #8 Email Would you like to add another provider?YesNoI agree to the following for Provider #9:*MIPS COACHING: 1st Program Year ($250 per month 1st Clinician, $125 for each additional clinician)Provider #9 First Last Credentials Provider #9 NPIProvider #9 Email Would you like to add another provider?YesNoI agree to the following for Provider #10:*MIPS COACHING: 1st Program Year ($250 per month 1st Clinician, $125 for each additional clinician)Provider #10 First Last Credentials Provider #10 NPIProvider #10 Email Practice Name*Address* City State / Province / Region Contact Name* First Last Contact Phone*Contact Email*
