STI Quality Reporting Registry Enrollment (2024)

Practice Name*

Address*

Street Address City State / Province / Region

Contact Name*

First Last

Contact Phone*

Contact Email*

I agree to the following for Provider #1:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #1*

First Last Credentials

Provider #1 NPI*

Provider #1 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

Would you like to add another provider?

Yes
No

How are you reporting for the Quality Registry?*

As a Group
As Individual Providers

*Note, to report as a Group, you must have at least two providers in your practice.

I agree to the following for Provider #2:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #2

First Last Credentials

Provider #2 NPI

Provider #2 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

Would you like to add another provider?

Yes
No

I agree to the following for Provider #3:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #3

First Last Credentials

Provider #3 NPI

Provider #3 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

Would you like to add another provider?

Yes
No

I agree to the following for Provider #4:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #4

First Last Credentials

Provider #4 NPI

Provider #4 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

Would you like to add another provider?

Yes
No

I agree to the following for Provider #5:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #5

First Last Credentials

Provider #5 NPI

Provider #5 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

Would you like to add another provider?

Yes
No

I agree to the following for Provider #6:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #6

First Last Credentials

Provider #6 NPI

Provider #6 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

Would you like to add another provider?

Yes
No

I agree to the following for Provider #7:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #7

First Last Credentials

Provider #7 NPI

Provider #7 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

Would you like to add another provider?

Yes
No

I agree to the following for Provider #8:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #8

First Last Credentials

Provider #8 NPI

Provider #8 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

Would you like to add another provider?

Yes
No

I agree to the following for Provider #9:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #9

First Last Credentials

Provider #9 NPI

Provider #9 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

Would you like to add another provider?

Yes
No

I agree to the following for Provider #10:*

Certified Quality Registry Program (enrollment fee is $590 per provider, per performance year)

*Note: Enrollment fee is waived if provider is already enrolled in the MIPS Assistance Program. Please reference our MIPS Assistance Program page for more information on program fees and details.*

Provider #10

First Last Credentials

Provider #10 NPI

Provider #10 Email*

A unique email address is needed for each provider enrolling for STI Quality Reporting Registry. If a unique address is not provided for each provider, your enrollment will be delayed until one is provided.

STI Quality Reporting Registry Enrollment (2024)

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