Surescripts Health Information Network Announced as Designated QHIN| See All

Form 2

QHIN Application

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

The questions in this Part correspond to Part 4, Sections I.2 and I.3 of the QHIN Onboarding & Designation SOP.

Part I – Basic Applicant Information

Part II – Organizational Requirements

Question 2 Question 3

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

Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12
Question 13

Part IV – Organizational Infrastructure and Legal Authority

Question 14 Question 15 Question 16 Question 17 Question 18 Question 19 Question 20 Question 21 Question 22 Question 23 Question 24 Question 25 Question 26 Question 27 Question 28 Question 29 Question 30 Question 31 Question 32 Question 33 Question 34

Part V – QHIN Privacy and Security Requirements

Question 35 Question 36 Question 37 Question 38 Question 39 Question 40 Question 41 Question 42 Question 43

Part VI – Project Plan

Part VII - Background References

Question 45
Question 46

Part VIII - Attestation

Question 11.

Please check all technical components you currently support and provide the corresponding details with respect to your current network and Designated Network:

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Record Type ID

Submission ID*

QHIN Query

QHIN Query

QHIN Query Support Description

Describe your ability to support query functionality as outlined in the (QHIN) Technical Framework (QTF) or other functionally comparable exchange method, including length of experience supporting such functionality, and specifically note what transaction standards are used.

Query Secure Channel Standard(s) / Profile(s) Used

please list all separated by comma’s

Mutual Authentication Standard(s)

please list all separated by comma’s

User Authentication Standard(s)

please list all separated by comma’s

Authorization & Exchange Purpose Standard(s)

please list all separated by comma’s

Query for Patients Standard(s)

please list all separated by comma’s

Document Query and Retrieve Standard(s)

please list all separated by comma’s

Auditing Standard(s)

please list all separated by comma’s

QHIN Message Delivery

QHIN Message Delivery

QHIN Message Delivery Support

Describe your ability to support message delivery, including length of experience supporting such functionality, and specifically note what transaction standards are used.

Record Location Service

Record Location Service; and/or

Enterprise Master Patient Index

Enterprise Master Patient Index; or

Federated Patient Discovery

Federated Patient Discovery; or

Other innovative method (please explain)

Other innovative method (please explain)

Please describe*

Optional File Upload

Drop files here or

Accepted file types: xls, xlsx, pdf, doc, docx, Max. file size: 128 MB.

Have a Question?

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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