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HSX Access Intake Form

Applicant Description

1.Applicant Contact Information(Required.)
2.Project/Solution Name(Required.)
3.Please indicate the data you hope to POST (send to) HSX Access to send downstream (to a provider/payer/healthcare consumer):
4.Please indicate the data you hope to GET (receive) from HSX Access:
5.What is your expected transaction volume? Please provide units.(Required.)
6.If HSX Access will be storing clinical information, what are the specific Data Points being stored? If HSX Access is not storing any clinical information on behalf of the applicant, please put N/A.
7.If clinical data is being stored by your organization, what are the specific Data Points to be stored by HSX Access Partner, including detail on privacy and security compliance for PHI storage, (i.e., HIPAA Compliance, HITRUST Certification, etc?)(Required.)
8.What is your anticipated project start date and anticipated production readiness?(Required.)
Anticipated Start Date
Anticipated Production Ready Date
9.What is your product development timeline? Include specific milestones.(Required.)
10.Please attach a diagram of the expected data workflow from start to finish for the proposed solution.(Required.)
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