Accreditation Application Form

Accreditation Application Form
Accreditation Program(s) Desired: (Check all that apply)
Is your organization already HITRUST certified?
What date were you last certified?

MonthDayYear
Date
Do you want to become HITRUST Certified?
What date would you need to be certified by?

MonthDayYear
Date
Company Information
Organization Legal Name
Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization Website
Upload Company Logo

Cancelof
Upload Company Logo

Please upload your Company Logo here: https://directtrust.app.box.com/f/70ff84f50ac145b092363fbe54121208
Did you upload your logo to the above link?
Primary Contact Information
Primary Contact Name

First NameLast Name
Primary Contact Title
Primary Contact Email
example@example.com
Primary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Information
Secondary Contact Name

First NameLast Name
Secondary Contact Title
Secondary Contact Email
example@example.com
Secondary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Is your billing contact your Primary or Secondary Contact?
Which contact is your billing contact?
Billing Contact Information
Billing Contact Name

First NameLast Name
Billing Contact Title
Billing Contact Email
example@example.com
Billing Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Marketing Contact Information
Marketing Contact Name

First NameLast Name
Marketing Contact Title
Marketing Contact Email
example@example.com
Marketing Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Accreditation Information
Annual Gross Revenue
Do you have a HIPAA Privacy and Security Certification from another organization?
Do you use cloud services?
Cloud Service Provider Name(s)
Cloud Service Provider Address(es)
Is your Organization the corporate entity or a subsidiary of a larger Organization?
Name of Parent Organization
How many in scope locations do you currently have?
In Scope Location Details
Using the free form entry box below, please provide the following information for each in scope location:

Name, Type, Function, and Address (including Country)

Type: Organization Site, Outsourced Site

Function: Backup Media Storage, CA Operations, Cloud Service Provider, Corporate Main Operations, Customer Service/Help Desk, Data Center, Disaster Recovery, HIE Technical Operations, HISP Operations, Lockbox Operations, Network and System Administrators, Printing, Product Development, RA Operations, Scanning, Other
In Scope Location Details
Additional Comments
Comments (add any information that may be pertinent to your organization)
Should be Empty:

Accreditation Application Form

Company Information

Upload Company Logo

Primary Contact Information

Secondary Contact Information

Billing Contact Information

Marketing Contact Information

Accreditation Information

In Scope Location Details

Name, Type, Function, and Address (including Country)

Additional Comments