Utah Medicaid Vendor Service

PHR Application Name: *

PHR Company Name: *

Callback URL/Redirect URL: *

Authoritative PHR Application Representative Contact Information *

First Name: *

Last Name: *

Business Email: *

Business Phone Number: *

Authoritative PHR Application Representative Attestation

Representative must read and attest that the application meets each of the following provisions:

Clearly explains to Medicaid clients (Client) that their PHR data is no longer covered by HIPAA once the Client directs their PHR to be exchanged with most apps.
Provides customer support contact information to Clients who may need assistance.
Assures protection of Client’s privacy as per CMS guidelines (Best Practices for Payers and App Developers).
Privacy policy, notice, and procedures include:
- How a Client’s PHR may be accessed, exchanged, or used by any person or other entity, including whether the Client’s PHR may be shared or sold at any time (including in the future).
- A requirement for express consent from the Client before the Client’s PHR is accessed, exchanged, or used, including receiving express consent before the Client’s PHR is shared or sold (other than disclosures required by law or disclosures necessary in connection with the sale of the application or a similar transaction).
- If the PHR application will access any other information from the Client’s device.
- How the Client can discontinue app access to the Client’s PHR data, and what the app’s policy and process is for disposing of the Client’s data once the Client has withdrawn consent.
- The PHR application assigns unique identifiers to each Client who registers for an account to view the Client’s PHR data.

I attest that the application meets each of the above listed provisions.*

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CARIN Alliance Code of Conduct	https://www.carinalliance.com/our-work/trust-frameworkand-code-of-conduct/
CMS Best Practices for Payers and App Developers	https://www.cms.gov/files/document/best-practices-payers-and-app-developers.pdf
CMS Regulations and Guidelines	https://www.cms.gov/Regulations-andGuidance/Guidance/Interoperability/index
Privacy, Security, and HIPAA	https://www.healthit.gov/topic/privacy-security-and-hipaa
ONC Model Privacy Notice	https://www.healthit.gov/topic/privacy-security-and-hipaa/model-privacy-notice-mpn