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North Carolina Health Information Exchange Authority <br />FULL NC HIEA PARTICIPATION AGREEMENT INSTRUCTIONS <br />Please read these instructions carefully. Missing or inaccurate information will delay processing of your agreement. <br />1. Read and review the entire NC HIEA Participation Agreement with your legal department, Contract <br />Administrator, or other authorized staff member.If you have already signed a previous participation <br />agreement with NC HIEA, signing and executing this document will replace and supersede any <br />previous participation agreements. <br />2. On page 2, include the legal entity name of the provider or facility. If you “Do business as” another identity, <br />please include that information. The address listed should be the appropriate USPS mailing address. <br />3. Please have an authorized signatory sign page 28 under “Participant”and page 38 under “Covered Entity.” <br />Wet ink or digital signatures will be accepted, but text signatures will not. By signing these pages, you are <br />agreeing to the terms of the Participation Agreement and to the Business Associate Agreement in <br />Attachment 5. The agreement cannot be executed by NC HIEA without signatures on these pages. <br />4. In Attachment 1 on page 29, please provide your contact information for your organization where you will <br />receive formal Notices from NC HIEA. <br />5. In Attachment 2 on page 30, please provide the name and contact information for your: Participant Account <br />Administrator, Contract Administrator, and Technical Services Contact (CIO or other Technical Support <br />contact) where indicated. If one person fulfills multiple roles, please indicate this. <br />6. In Attachment 3 on page 31, please provide information about your practice, your EMR or EHR vendor, <br />what health system or HIE your organization is a member of, and the remaining requested information. <br />Please also review the Technical Specifications, Targeted Data Standards, and On-Boarding Process that you <br />are required to comply with. <br />7. In Attachment 4 on page34,please identify your Participating Entitiesand locations,if applicable. Please <br />see Section 2.37 for the definition of a Participating Entity. If you have more than 10 entities or locations, <br />please attach an spreadsheet with all the requested information for the entities. Incomplete information in this <br />section will delay the processing of your agreement. <br />8. In Attachment 5 starting on page 36, please review the Business Associate Agreement.Please include the <br />legal entity name of the provider or facility next to “name of Participant,” and sign on page 38 under <br />“Covered Entity.” <br />9. In Attachment 11, please review the information and sign the document to demonstrate your intent to submit <br />data to and be actively engaged with the NC HealthConnex Diabetes Registry. <br />10. Please return the entire 51-page signed Participation Agreement to the North Carolina Health Information <br />Exchange Authority via email to HIEA@NC.gov. Or you can mail it to the address below. <br />NC Health Information Exchange Authority Legal Team <br />Mail Service Center 4101 <br />Raleigh, NC 27699-4101 <br />The North Carolina Health Information Exchange Authority will confirm receipt of the fully executed <br />Participation Agreement by email to one or more of the individuals identified in Attachment 2 on page 30. This <br />email will include important contact information for technical assistance and the next steps in the connection <br />process. <br />DocuSign Envelope ID: 47B4445A-C7CA-4D2E-9075-2AFD82F82DEC