Form: CTEN Application for TPO Trust Profile
Effective: 15 September 2017 / Version: 1.0
I. Instructions
This form should be completed by any organization wishing to onboard to the California Trusted Exchange Network (CTEN) unless the candidate Participant intends to use a pre-approved testing plan.
Before beginning, all Applicants must have reviewed the CalDURSA and signed the Joinder Agreement.
Submit all pages of this form with appropriate information completed, along with any attachments, to the CTEN Administrator at .
For more information on the policies and procedures that govern the CTEN and the Treatment, Payment, and Operations Trust Profile, see:
· CIC OPP-1, Review and Disposition of Applications for Participation
· CTEN EPP-8, Policy for Transactions for Treatment, Payment, and Operations
· CTEN EPP-9, Procedure for Onboarding for Treatment, Payment, and Operations
II. Contact Information
The primary point of contact listed here should be a member of the candidate organization that can take responsibility for its participation in CTEN.
Primary Point of ContactName: / Click or tap here to enter text.
Title: / Click or tap here to enter text.
Organization: / Click or tap here to enter text.
Phone Number: / Click or tap here to enter text.
Email Address: / Click or tap here to enter text.
Mailing Address: / Click or tap here to enter text.
The technical point of contact and testing point of contact listed below will be used during the testing phase of the onboarding process. They should be able to address technical issues and questions regarding the candidate organization’s implementation and assist in peer-to-peer testing with other Participants, respectively.
Technical Point of ContactName: / Click or tap here to enter text.
Organization: / Click or tap here to enter text.
Phone Number: / Click or tap here to enter text.
Mobile Number: / Click or tap here to enter text.
Email Address: / Click or tap here to enter text.
Testing Point of Contact
Name: / Click or tap here to enter text.
Organization: / Click or tap here to enter text.
Phone Number: / Click or tap here to enter text.
Mobile Number: / Click or tap here to enter text.
Email Address: / Click or tap here to enter text.
III. Eligibility
1) Have you signed the Joinder Agreement of the CalDURSA?
☐ Yes Date: Click or tap here to enter text.
☐ No
You may continue with the application process, but the CIC will not consider your application until you have signed the Joinder Agreement and submitted it to CAHIE.
2) Have you previously applied to and been approved by the CIC to be a CTEN Participant in the Treatment, Payment, and Operations Trust Profile?
☐ Yes
☐ No
STOP! If you answered “Yes” above, you do NOT need to complete this form. Instead, submit a CTEN Testing Plan for a new transaction.
The remainder of this section must be completed by all organizations that are not already CTEN Participants and answered “No” to the previous question.
CIC policy OPP-1 identifies “General Eligibility Requirements” that all CTEN Participants must meet. For each requirement, indicate whether your organization meets this requirement, and, if applicable, add specific information requested for that requirement as evidence. All responses must be “Yes” for this application to be processed.
3) Are you a business in Good Standing[1] or a government agency, headquartered in the US?
☐ Yes Attach a Statement of Good Standing[2]
☐ No
4) Do you have business operations in the State of California?
☐ Yes Where? Click or tap here to enter text.
☐ No
5) Do you oversee and conduct electronic exchange of health information?
☐ Yes Where or for whom? Click or tap here to enter text.
☐ No
6) Do you have the organizational infrastructure and legal authority to comply with the obligations in the CalDURSA?
☐ Yes
☐ No
7) Do you have the organizational infrastructure and legal authority to require your participating users to comply with applicable requirements of the CalDURSA?
☐ Yes
☐ No
8) Do you intend to exchange information with other CTEN Participants for purposes of treatment, payment, and/or health care operations?
☐ Yes
☐ No
9) Do you have a system in a production-ready environment that complies with CTEN Service Specifications?
☐ Yes
☐ No, but are submitting new service specification(s) for approval
☐ No
If you answer “No, but are submitting new service specification(s) for approval”, you may proceed with this application, but onboarding is conditional upon approval of the new service specification.
10) Are you ready to begin exchanging information with other CTEN Participants in production?
☐ Yes
☐ No
IV. Obligations
CTEN EPP-8 identifies the “Obligations” or responsibilities required for transactions for treatment, payment, or health care operations. For the purposes of the CTEN, three Parties have been defined: Participants (you and your peers on the CTEN), their affiliated Subparticipant organizations (organizations that are your exchange partners), and the Authorized End Users of either.
For each obligation, you must:
- Check either “Attestation” or “Accreditation” to indicate how your organization meets the requirement;
- Describe the evidence of meeting the obligation; and
- Attach the relevant section to this form.
Acceptable evidence for “Attestation” might be a copy of a typical participant agreement or other contractual requirement between you and your customers, reference to the Model Modular Participant Agreement (MMPA) if you use it, or some other policy or procedure document. The description should be specific in listing the name of the document submitted as evidence and the specific section that meets the requirement. If the submitted document is proprietary, please ensure it is so marked.
Indicate “Accreditation” only if your organization and the applicable technical service have been certified or accredited by a program that also requires this obligation be met, and indicate the name of the certifying or accrediting body or program. Acceptable evidence for “Accreditation” might be the URL where certification or accreditation results are published or a copy of a certificate of successful certification or accreditation. The description should be specific in indicating where the obligation appears within certification or accreditation requirements.
A. Obligations under the CalDURSA
The following obligations are included in the CalDURSA which your organization has signed.
1) I have Subparticipant and/or Authorized End User access policies.
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
2) I employ a process to validate sufficient information to uniquely identify each person seeking to become an Authorized End User prior to issuing credentials.
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
3) I employ a process to ensure an Authorized End User uses issued credentials to verify identity prior to requesting health information.
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
4) I respond to all requests for information for treatment purposes (1)with the requested content or (2)that the information is not available.[3]
☐ Not applicable (my organization cannot respond to request for health information)
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
5) I request information in accordance with CalDURSA terms and conditions governing the use, confidentiality, privacy, and security of health information.
☐ Not applicable (my organization cannot make requests for health information)
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
6) I discipline any Authorized End Users or Subparticipants who fail to act in accordance with the terms and conditions of the CalDURSA.
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
7) I alert other CTEN Participants whose health information may have been breached and the CIC within one hour of reasonably believing a breach may have occurred.
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
8) I provide notification to all CTEN participants likely impacted by a breach and the CIC within 24 hours.
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
B. Obligations under CIC Policy
The following obligations are included in operating policies and procedures of the CIC. The applicant is strongly encouraged to review all CIC policies and procedures to become familiar with requirements and procedures not included here.
9) I will inform the CIC of all plans to modify or terminate a service on the CTEN.
☐ Acknowledgement
This obligation is acknowledged by the signature of the individual submitting this form.
10) I will inform the CIC of all CTEN service interruptions, prior to interruption if planned or as soon as reasonably practicable after the interruption begins if unplanned.
☐ Acknowledgement
This obligation is acknowledged by the signature of the individual submitting this form.
C. Obligations under CTEN Policy for Treatment, Payment, and Operations
The following obligations are listed in CTEN EPP-8 Policy for Treatment, Payment, and Operations and are specific to this Trust Profile.
1. Obligations of the Parties
11) I comply with all applicable state and federal laws and regulations.
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
2. Obligations of the Participant to other CTEN Participants
12) I will ensure that any Authorized End User, including those of Subparticipants, whose authorization has been discontinued is no longer able to use CTEN services.
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
13) I will monitor the expiration date(s) of all of the digital certificate(s) submitted, and ensure that CAIHE receives new certificate(s) prior to expiration.
☐ Not applicable (digital certificates are not used in my transactions)
☐ Attestation
☐ Accreditation What program? Click or tap here to enter text.
Describe the evidence you are submitting:
Click or tap here to enter text.
14) I acknowledge that the CIC may modify EPP-8 requirements as the needs of the CTEN change and that a condition of ongoing Participation status may depend on submitting additional information or evidence.
☐ Acknowledgement
This obligation is acknowledged by the signature of the individual submitting this form.
3. Obligations of the Participant to Authorized End Users
15) I acknowledge the obligations of Participants defined in Section 12 of the CalDURSA.
☐ Acknowledgement
This obligation is acknowledged by the signature of the individual submitting this form.
4. Obligations of the Authorized End Users
16) I acknowledge the obligations of Authorized End Users defined in Section 12.2 of the CalDURSA.
☐ Acknowledgement
This obligation is acknowledged by the signature of the individual submitting this form.
V. Completed By
The person completing this form must be able to answer questions regarding the policies and practices of the candidate organization during processing of this application.
The person signing this form affirms, by that signature, that the above information is true, complete, and accurate, and is authorized to execute this form on behalf of the candidate organization.
Completed by:Contact: / ☐ Primary Point of Contact
☐ Technical Point of Contact
☐ Other: / Name: / Click or tap here to enter text.
Email Address: / Click or tap here to enter text.
Signed by:
☐ Primary Point of Contact
☐ Other: / Name: / Click or tap here to enter text.
Title: / Click or tap here to enter text.
Phone Number: / Click or tap here to enter text.
Email Address: / Click or tap here to enter text.
Signed:
Dated:
California Trusted Exchange Network Page 2 of 9
CTEN Appication for TPO Trust Profile
[1] Defined in OPP-1 Review and Disposition of Applications for Participation
[2] A Statement of Good Standing can usually be obtained from the government agency chartering your business.
[3] The CalDURSA allows an organization to respond that no information is available if a request violates its local policy for disclosing health information. The organization must, however, respond.