HSX Access Intake Form Applicant Description Question Title * 1. Applicant Contact Information Name * Company * Address * Address 2 City/Town * State/Province * ZIP/Postal Code * Country * Email Address * Phone Number Question Title * 2. Project/Solution Name Question Title * 3. Please indicate the data you hope to POST (send to) HSX Access to send downstream (to a provider/payer/healthcare consumer): POST Patient Activity POST Patient Blood Pressure POST Patient Glucose POST Patient Oxygen POST Patient Sleep POST Patient Weight POST Send DIRECT Message POST Send DIRECT Message with CCDA Question Title * 4. Please indicate the data you hope to GET (receive) from HSX Access: GET Patients GET Patient by ID GET Patient Allergies GET Patient Allergy GET Patient Attachments GET Patient Attachment GET Patient C32 CCD GET Patient Summarization of Episode Note CCDA GET Patient Diagnoses GET Patient Diagnosis GET Patient Encounters GET Patient Encounter GET Patient Immunizations GET Patient Immunization GET Patient Labs GET Patient Lab GET Patient Lab Observation Group GET Patient Lab Observation Group Observation GET Patient Lab Observation Group Specimen GET Patient Medications GET Patient Medication GET Patient Medication Prescriptions GET Patient Prescriptions GET Patient Prescription GET Patient Problems GET Patient Problem GET Patient Procedures GET Patient Procedure GET Patient Readings GET Patient Reading GET Patient Social Histories GET Patient Social History GET Patient Vital Signs GET Patient Vital Sign GET Providers GET Provider GET Provider Patients GET Repository Data Sources Question Title * 5. What is your expected transaction volume? Please provide units. Question Title * 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. Question Title * 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?) Question Title * 8. What is your anticipated project start date and anticipated production readiness? Anticipated Start Date Date Anticipated Production Ready Date Date Question Title * 9. What is your product development timeline? Include specific milestones. Question Title * 10. Please attach a diagram of the expected data workflow from start to finish for the proposed solution. DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Please attach a diagram of the expected data workflow from start to finish for the proposed solution. Next
