Form 2

QHIN Application

Part V - QHIN Privacy and Security Requirements

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 37.

Attestation: Applicant’s Chief Information Security Officer (CISO) named in Question 1 has or will have executive-level responsibility for monitoring and maintaining Signatory’s overall security posture related to Signatory’s participation in TEFCA exchange via a Framework Agreement.

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ATTESTATION: BY SELECTING THIS, I ATTEST THE ABOVE TO BE TRUE*

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