Practice Pro Registry Opt-In – MIPS 2021 (Click here for MIPS Reporting Guide and Plans) Primary Point-of-Contact for MIPS ImplementationContact Name *Practice Name *Contact Email *Contact Phone * MIPS Reporting OptionsHow will you be reporting? *GROUP Pricing: $400 for first clinic location, $50 each additional location (per year) INDIVIDUAL: $200 per provider (per year)Group Reporting (2+ Providers)Individual ReportingHow many providers will be reporting? *Select an option for registry submission: *For detailed pricing and option details, please see MIPS reporting guide here.Practice Pro Registry (no FOTO integration)Practice Pro Registry (FOTO OMLite integration)External Registry (Need Data Export)No registry (claims based)Not participating in MIPSPractice Pro Registry (Voluntary Reporting)Instructions After submission of this form, we will send you separate agreements for service, data consent and release. *FOTO subscriptions and invoicing are handled separately. Please contact FOTO for more details. VerificationPlease enter any two digits with no spaces (Example: 12) *This box is for spam protection - <strong>please leave it blank</strong>:
