DirectTrust HISP Accreditation Application

Thank you for your interest in the DirectTrust.org, Inc. (“DirectTrust.org”) Accreditation Program. This is an application to become a DirectTrust Accredited HISP. To keep the administrative process for the Accreditation Program simple, this application form has three parts.

Part a:  Download the Application Agreement

Part b:  Submit online web Application Form OR downloadable printable Application Form that specifies basic demographic and contact information.  The executed Application Agreement must be included with Application Form.

Part c:  Pay online Application Fee via Paypal or mail application fee of $4500 (address below)

Once we have confirmed your eligibility for the Program, you will securely receive an ID and Password to access the Accreditation Program Applicant Access pages to start the Accreditation Process.

If you have any questions, please direct them to apadmin@directtrust.org

 

Part a: Download the Application Agreement

Download, print, review, and execute an agreement that binds your HISP to the requirements and obligations of the DirectTrust HISP Accreditation Program.  The executed agreement must be included with your application.

Part b: Application for DirectTrust HISP Accreditation

Online Web Application Form OR Printable Form (below the online application) specifies basic demographic and contact information.  Executed Application Agreement must be included with application.

Online Application Form for DirectTrust HISP Accreditation



Application Agreement upload

Upload the executed Application Agreement here.



Organization Information

Legal Name

Mailing Address

URL of website

Legal or Tax Classification

Is this a new accreditation or a reaccreditation?

Logo for your organization to be used on our website after Accreditation is approved
Acceptable file formats: .jpg or .png. Landscape orientation preferred.



Contact Person Information

(Your organization’s delegate to represent them within the DirectTrust.org Accreditation Program)

Name

Title

Email address

Mailing Address

Telephone Number

Mobile Phone Number



Secondary Contact Information

Name

Phone Number

Email Address



HIPAA Privacy and Security Certification

If currently certified, please complete the following

Certification Organization

Date of Expiration

If not currently certified and in progress, please enter the expected completion date

Certification Organization

Expected Date of Completion



Part c: Pay your HISP Accreditation Application Fee

You can pay your DirectTrust Accreditation application fee by either sending your application payment to us by mail to the address listed below (If you are mailing in your application form, you may send the payment in the same envelope) OR use the PayPal option below.

DirectTrust HISP Accreditation Fee: $4,500 

The DirectTrust HISP Accreditation Fee is valid for two years (i.e. it is not annual).  For new organizations, this is paid as part of the application process.

 

If you prefer to mail a check, please send payment to:

Mail address:
DirectTrust.org Accreditation Program Services
PO Box 2885
Blairsville, GA 30514
United States

Make checks payable to:
DirectTrust.org

If you prefer to pay online using PayPal:

Name of your Organization