MIPS Coaching – 2nd Program Year MIPS Coaching – 2nd Program Year MIPS Coaching: 2nd Program Year (2018) I agree to the following for Provider #1:*MIPS COACHING: 2nd Program Year ($175 per month 1st Clinician, $95 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: 2nd Program Year ($175 per month 1st Clinician, $95 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: 2nd Program Year ($175 per month 1st Clinician, $95 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: 2nd Program Year ($175 per month 1st Clinician, $95 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: 2nd Program Year ($175 per month 1st Clinician, $95 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: 2nd Program Year ($175 per month 1st Clinician, $95 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: 2nd Program Year ($175 per month 1st Clinician, $95 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: 2nd Program Year ($175 per month 1st Clinician, $95 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: 2nd Program Year ($175 per month 1st Clinician, $95 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: 2nd Program Year ($175 per month 1st Clinician, $95 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*
