Accreditation Application Form

Accreditation Application Form
Accreditation Program(s) Desired: (Check all that apply)*

Accountable Care OrganizationCertificate AuthorityCARIN Code of Conduct for Consumer-Facing ApplicationsData Registrye-Prescribing - Electronic Health Networke-Prescribing of Controlled Substances for Pharmacy Applications (Certification)e-Prescribing of Controlled Substances for Prescribing Applications (Certification)Financial Services - Electronic Health NetworkFinancial Services - LockboxHealth AppHealth Information ExchangeHealth Information Service ProvidersHITRUSTHealthcare Network - Electronic Health NetworkHealthcare Network - Medical BillerHealthcare Network - PayerHealthcare Network - Third Party AdministratorManagement Service OrganizationOutsourced Services for Accountable Care OrganizationsOutsourced Services for Call Center OperationsOutsourced Services for Cloud Service ProvidersOutsourced Services for Data Center facilities and ServicesOutsourced Services for Disaster Recovery Facilities and ServicesOutsourced Services for Health Information ExchangeOutsourced Services for Media Storage Facilities and ServicesOutsourced Services for Systems and Network Administration ServicesOutsourced Services for Printing Service OperationsOutsourced Services for Product DevelopmentOutsourced Services for Scanning Service OperationsPractice Management SystemPrivacy & SecurityRegistration AuthorityRegistration Authority - Federal Public Key InfrastructureTrusted Dynamic Registration & Authentication - Basic (Certification)Trusted Dynamic Registration & Authentication - ComprehensiveTrusted Network for Health Information Network ApplicantsTrusted Network for QHIN Participants and Participant MembersUDAP Client App - BasicUDAP Client AppUDAP Identity ProviderUDAP Server
Is your organization already HITRUST certified?*

YesNo
What date were you last certified?

MonthDayYear
Date
Do you want to become HITRUST Certified?

YesNo
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.
Organization Website*
Upload Company Logo

Cancelof
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.
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.
Is your billing contact your Primary or Secondary Contact?

YesNo
Which contact is your billing contact?

PrimarySecondary
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.
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.
Accreditation Information
Annual Gross Revenue*
Do you have a HIPAA Privacy and Security Certification from another organization?*
Do you use cloud services?*

YesNo
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

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