Question 47.

Attestation: By submitting this application, the Applicant represents and warrants that the information provided herein is accurate and complete, to the best of its knowledge. Applicant understands and agrees that the RCE is expressly relying upon the information in this application, including all attachments and documents incorporated by reference to evaluate whether the Applicant meets the criteria to be Designated. If the RCE determines that material information in this application is not accurate or complete, the RCE may refuse to Designate the Applicant, withdraw the Applicant from Onboarding, and terminate the Common Agreement that the Applicant is submitting with this application in accordance with 16.2.2 of the Common Agreement.

If there are requirements in the QHIN Onboarding & Designation SOP that are not required to complete this application, but are required for an Applicant to be Designated, those requirements must be addressed during the Onboarding and Designation process. By typing your name below and clicking “Submit,” you are electronically signing this application and, in doing so, you represent and warrant that you are authorized to submit this application on behalf of the Applicant and that you have the authority to legally bind the Applicant to the attestation set forth above and the question-specific attestations contained herein.