Provider Access API Choice

Provider Access FHIR API – Provider Request Form
Purpose of this form

This form is used to:
- Validate the identity of the requesting provider organization
- Confirm the treatment relationship and eligibility for access
- Understand the technical environment (EHR/vendor system)
- Establish contacts for onboarding, security, and support
- Provision secure access to the Provider Access FHIR API
Provider Organization Information
Legal Organization Name
Tax Identification Number (TIN)
National Provider Identifier (NPI) – Organization (Type 2)
Provider Organization Type (pick more than one?)

Other
Provider Organization Contact Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Organization Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Requesting Individual
Requestor's Name

First NameLast Name
Requestor's Title / Role
Requestor's Email
example@example.com
Requestor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Organization (pick 1?)

Other
Technical / EHR System Information
Primary EHR / Clinical System Name
EHR Vendor
EHR Version (if known)
Is this request being made by an EHR vendor or integration partner?
EHR vendor or integration partner contact information
Vendor / Integration Partner Name
Vendor Contact Full Name

First NameLast Name
Vendor Contact Email
example@example.com
Vendor Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
API Integration Details
Intended Use of Data (check all that apply)

Other
Will data be accessed via (pick more than one?)

Other
Expected Integration Method

Currently, the FHIR API is Backend services (system-to-system utilizing OpenID Connect 1.0, OAuth 2.0 standards) integration method only.
Requested Environment(s)
Patient Attribution and Access Justification
Describe how your organization establishes a treatment relationship with patients:
How will your system ensure that only authorized users access patient data?
Security and Compliance
Does your organization comply with HIPAA requirements?
Does your organization have role-based access controls in place?
Do you maintain audit logs of system access?
Security Contact Full Name

First NameLast Name
Security Contact Email
example@example.com
Security Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contacts
Technical Contact
Technical Contact Full Name

First NameLast Name
Technical Contact Title
Technical Contact Email
example@example.com
Technical Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Implementation / Project Contact
Implementation / Project Contact Name

First NameLast Name
Implementation / Project Contact Title
Implementation / Project Contact Email
example@example.com
Implementation / Project Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Operation / Business Contact
Operation / Business Contact Name

First NameLast Name
Operation / Business Contact Title
Operation / Business Contact Email
example@example.com
Operation / Business Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Attestations and Agreements
By submitting this form, the organization attests that:
Attestor Name

First NameLast Name
Attestor e-Sig?
Attestor Title
Attestation Date

MonthDayYear
Should be Empty:

Provider Access FHIR API – Provider Request Form

Provider Organization Information

Requesting Individual

Technical / EHR System Information

EHR vendor or integration partner contact information

API Integration Details

Patient Attribution and Access Justification

Security and Compliance

Primary Contacts

Technical Contact

Implementation / Project Contact

Operation / Business Contact

Attestations and Agreements