Accreditation Process Overview

The following is a description of the steps that a HISP must go through to achieve its HISP Accreditation from DirectTrust.

The following diagram outlines the Accreditation Process.  (Click to enlarge)

The specific steps are outlined below.


Step 1: Getting Started

The Application Form and Application Agreement materials may be accessed on the application page.

Each Candidate HISP starts the Accreditation Process by:

  1. Downloading and executing the Application Agreement.
  2. Completing and submitting an online application form. The executed Application Agreement must be included with the application form.
  3. Remitting the Accreditation Audit Fee.

The Applicant HISP must complete the Forms and submit the Payment as instructed before the Accreditation Program starts.

After the Application Form and Payment have been processed by DirectTrust, the Applicant HISP will securely receive login information to access the Applicant Access portion of this website to start the Accreditation Process.

Step 2: Login and Download Self Attestation Document

The HISP will use the login credentials securely received from DirectTrust to login and access the Accreditation Program website at Once logged in, the HISP may download the Self Attestation Document and the Companion Guide.

The Self Attestation Document contains all of the criteria that a HISP must provide answers to and in some cases evidence that demonstrate that it is in compliance with the DirectTrust Community HISP Policy.

The Self Attestation Document and associated evidence are uploaded for review by the DirectTrust Reviewer. The Reviewer will grade the criteria and artifacts to develop a score. The Audit Score is used to determine if the HISP passes or fails the audit.

The Self Attestation criteria is classified into two main categories: Mandatory and Not Mandatory. The Mandatory criteria is scored on a pass/fail basis and the Not Mandatory criteria is scored on a points basis. All of the Mandatory criteria must receive a Pass score. If any of the Mandatory criteria is failed, then the entire audit is failed. The Not Mandatory audit criteria must achieve a passing score that is specified in the Self Attestation Document.

The Companion Guide provides guidance and an explanation for how to respond to each of the Audit Criteria. It is strongly recommended that the HISP download and review the Companion Guide before completing the Self Attestation criteria questions. You may download the Companion guide from the Accreditation Program website.

Step 3: HISP Completes Self Attestation Document

Using the Companion Guide for assistance, the Applicant HISP works to complete the questions in the Self Attestation Document.

As part of answering the Self Attestation questions, the Applicant HISP will be asked to upload evidence that is required to prove that they are in compliance with DirectTrust Community Policy.  This upload will be done on the Accreditation Program website.

Step 4: DirectTrust Review Of Self Attestation Document And Evidence

After the Applicant HISP uploads their responses to the Self Attestation Questions and uploads their evidence, the DirectTrust Reviewer will review them for completeness and to ensure that the HISP is operating within the HISP Policy guidelines.

During the review process, the Reviewer may have questions or require consultation with the Applicant HISP. This process of consultation with the Applicant HISP may require several iterations where the Reviewer may request additional information. Before the audit has completed the Applicant must upload proof of receiving its HIPAA Privacy and Security Certification or Accreditation before the HISP can be approved for accreditation.

If the HIPAA Privacy and Security Certification or Accreditation, Self Attestation and artifacts are in good order, the HISP will be notified that the Audit has been completed with success and the results will be sent to the DirectTrust Accreditation Administrator for review.

Step 5: DirectTrust HISP Accreditation Approval

The DirectTrust Accreditation Administrator will vote to approve the HISP’s application for accreditation. Upon approval by the DirectTrust Accreditation Administrator will make a recommendation to the DirectTrust Board of Directors for approval. Once the DirectTrust Board of Directors votes to approve the HISP’s accreditation, the DirectTrust Web site will be updated to indicate its accredited status and notification will be sent to the HISP as proof of its accreditation.

After an Applicant HISP is approved, it will receive a logo for display on its web site and other marketing materials.

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