Healthcare Cerner Direct Account Application

Healthcare Cerner Direct Account Application

Application for Cerner Direct secure messaging account. Organization Name:   Application Date:

Organization Information

Hospital   Clinic   Physician Practice   Laboratory   Other

Requestor / Technical Contact

Requested Account Details

Individual Clinician   Organization Shared Address   System-to-System (Mirth/Interface)   Practice Portal

Send   Receive   Send & Receive   Administrative / Account Manager

Security, Privacy & Attestations

By checking each attestation and signing below, the applicant certifies that the organization will comply with all applicable federal and state laws governing protected health information and will maintain administrative, technical, and physical safeguards appropriate to the scope of access granted. The applicant understands that misuse of the Direct account, including unauthorized release of protected health information, may result in immediate suspension or termination of Direct privileges and other administrative or legal action.

I attest that the organization will act as the responsible party for all messages transmitted and received via the requested Direct address.

I attest that all account users will complete required privacy and security training prior to use and annually thereafter.

I attest that the organization will properly manage private keys and certificates, including revocation requests when a user leaves or an account is compromised.

I agree to notify the organization's governance authority and the administrator within 24 hours of any suspected compromise of credentials or unauthorized disclosure involving the Direct account.

I acknowledge that activity will be logged and monitored and that the organization will cooperate with audits and investigations related to account usage.

HIPAA / Privacy Acknowledgment

The applicant hereby acknowledges responsibility for ensuring that all use of the Direct address complies with HIPAA privacy and security requirements. The applicant further affirms that the Direct address will be used only for the authorized transmission of protected health information necessary for treatment, payment, or healthcare operations, as permitted by law.

I acknowledge and accept the HIPAA-related responsibilities associated with establishing and operating a Direct address.

Account Term, Ownership & Expiration

Account ownership remains with the organization named above. The organization authorizes the issuing authority to provision the requested Direct address. This authorization will remain in effect until revoked in writing or upon notification of employee separation or change in operational need.

Requested Expiration Date (if applicable):

Supporting Documentation

Include required documentation with this application. Typical supporting documents include proof of identity for requestor/administrator, NPI confirmation, and organizational authorization. Failure to provide required documents may delay account provisioning.

Certification

I certify under penalty of perjury that I am authorized to submit this application on behalf of the organization; that the information provided herein is true, complete and accurate to the best of my knowledge; and that I accept responsibility for compliance with the security, privacy and operational requirements described above. I understand that false statements may result in denial or revocation of an account and may subject me or the organization to disciplinary or legal action.

Sign Now