Form 2

QHIN Application

Part I - Basic Applicant Information

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 1.

Please complete the following fields.

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List all other names under which the applicant does business (Doing Business As, Alias, Trademarks, etc.)
(If Applicant is a wholly-owned subsidiary and will be relying on Parent’s Current Network to demonstrate Historic Experience)

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If you have a question at any time during the application process please feel free to contact the RCE team. We'll be happy to assist you.

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