Self Sign Up - Cerner Direct Referrals

Cerner Direct HISP Application

Organization Information

Legal Business Name

Street Address 1

Street Address 2

City

State

Zip Code

Authorized Representative Contact Information

First Name

Last Name

Phone

Healthcare Category

If you are not a Covered Entity as defined by HIPAA, select one (no selection indicates Covered Entity Status):

Business Associate as defined by HIPAA

Non-HIPAA Healthcare Entity defined as an entity that has an appropriate healthcare-related need to exchange Direct messages and which agrees to handle protected health information with privacy and security protections that are at least as protective as those required by HIPAA.

Direct Email Domain

If your organization already has a direct domain please enter it below. If your organization doesn't have a direct domain please enter what you would like the domain to be.

Domain

Primary Contacts (optional)

Contact Person 1

Name

Phone

Contact Person 2

Name

Phone

Discard