QHIN Application

Provide information that indicates the financial health of the organization.

Note: You must submit the following information at a minimum:

1. *A copy of your most recent independent auditor’s report, which must have been signed by the auditor no more than 12 months prior to the date of submission of your application. You must submit the auditor’s opinion letter and may submit the supporting financial reports. The RCE may request additional information in the form of complete financial statements if needed to verify the financial health of the organization.
   Auditor’s report and/or supporting documentation must also include the following:
   
   1. Have financial statements been audited in accordance with Generally Accepted Accounting Principles? (Yes/No). If no, please provide additional information re: the level of financial review performed by an independent accountant;
   2. Year-end of most recent audit; and
   3. The audit opinion issued by our independent auditor was:
      1. An unqualified audit opinion
      2. A qualified audit opinion (provide detail of the qualification)
      3. An audit opinion in which the auditors expressed substantial doubt about Applicant or Parent’s ability to continue as a going concern for a reasonable period of time
      4. Other type of opinion (provide detail)

Attestation: Applicant (a) is financially stable and has the fiscal resources to support operating as a QHIN without placing a financial strain on the rest of the organization; (b) has available a minimum amount of cash, cash equivalents, or availability under borrowing arrangements through a commercial lender (i.e., a line of credit) equal to six (6) months of operating reserves; and (c) has completed all mandatory filings with the Internal Revenue Service and Securities and Exchange Commission.