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["QCDR Readiness Assessment"]
["Instructions:","This form will only work if you have Outlook installed on your PC or Mac.  If you use a different mail client please complete the form and copy/paste the requested information into an e-mail and send the e-mail to qcdr@asahq.org\n\nTo complete the form, first, ensure that you have enabled macros.  Next, complete the yellow highlighted fields, then click the submit button to send your information to ASA and determine your practice group."]
["Practice / Organization Name:"]
["Address 1:"]
["Address 2:"]
["City:"]
["State:",null,null,"Zip Code:"]
[]
["Primary Contact Information:",null,null,"Alternate Contact Information:"]
["First Name:",null,null,"First Name:"]
["Last Name:",null,null,"Last Name:"]
["Job Title:",null,null,"Job Title:"]
["Phone Number:",null,null,"Phone Number:"]
["E-mail:",null,null,"E-mail:"]
[]
["QCDR Readiness"]
["How many physician anesthesiologists providers does your practice have?"]
["How many non-physician anesthesiologists providers does your practice have?"]
["Is your practice actively submitting data to the AQI registry?"]
["Does your practice have a quality capture program in place (are you currently collecting outcomes data)?"]
["Has your practice previously reported PQRS measures to CMS?"]
["Has anyone from your practice reviewed the PQRS/QCDR measures for 2015?"]
["Based on the answers above you should reference the",null,null,{"$f":"IF(OR(F19=\"\",F20=\"\"),\"\",IF(F19=\"No\",\"QCDR 101 Toolkit\",IF(F20=\"No\",\"QCDR 201 Toolkit\",\"QCDR 301 Toolkit\")))","v":""}]

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["State Appreviations"]
["AL"]
["AK"]
["AZ"]
["AR"]
["CA"]
["CO"]
["CT"]
["DE"]
["DC"]
["FL"]
["GA"]
["HI"]
["ID"]
["IL"]
["IN"]
["IA"]
["KS"]
["KY"]
["LA"]
["ME"]
["MD"]
["MA"]
["MI"]
["MN"]
["MS"]
["MO"]
["MT"]
["NE"]
["NV"]
["HNH"]
["NJ"]
["NM"]
["NY"]
["NC"]
["ND"]
["OH"]
["OK"]
["OR"]
["PA"]
["RI"]
["SC"]
["SD"]
["TN"]
["TX"]
["UT"]
["VT"]
["VA"]
["WA"]
["WV"]
["WI "]
["WY"]