Form 2

QHIN Application

Part IV – Organizational Infrastructure and Legal Authority
The questions in this Part correspond to Part 4, Section I.4 of the QHIN Onboarding & Designation SOP.

Part I – Basic Applicant Information

Part II – Organizational Requirements

Part III – Exchange of Required Information and Ability to Perform Functions of a QHIN

Part IV – Organizational Infrastructure and Legal Authority

Part V – QHIN Privacy and Security Requirements

Part VI – Project Plan

Part VII - Background References

Part VIII - Attestation

Question 27.

Attestation: Neither Applicant nor, if applicable, Parent’s Current Network, is currently suspended from participation in any Health Information Network nor has been terminated from any Health Information Network in the twenty-four (24) months preceding submission of this application.

Applicant must attest to the above or state that Applicant cannot make this attestation.

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