Accredited Bundle Interop Results Reporting
My name (and regular email address if you wish to be contacted about this report)
Your answer
My Direct Address or EHR system name *
Your answer
Counter Party Direct Address or EHR system name (the one I sent to and/or received from) *
Your answer
Results of Sending from My Address to the Counter Party Address
Yes
No
Message was sent to this counter party (left my system without immediate fail)
Processed MDN was Received and Usable by my system
ONLY IF DISPATCHED REQUESTED: Dispatched MDN was received and usable by my system
Beyond the MDN: Counter party confirmed the message I sent to them was received and its payload could be incorporated (if receiving system is an EHR endpoint) OR was readable (if receiving system is a HISP endpoint). Counter party may alternatively confirm this in their own report.
Comments
Your answer
Filename of the payload I sent to this Counter Party, if any (leave blank if no C-CDA or XDM zip sent. (For example: list the C-CDA sample filename, XDM Zip sample filename, or other sample filename from the DirectTrust payload archive, or specify a new filename if not in archive, and send the sample to admin@directtrust.org with the same filename; otherwise leave this field blank; no PHI in sample files, please)
Your answer
Results of Receiving a message sent to My Address from the Counter Party Address
Yes
No
Beyond the MDN: Message I received FROM counter party was received by my system and its payload could be incorporated (my system is an EHR endpoint) OR was readable (my system is a HISP endpoint).
Filename of the payload I received from this Counter Party, if any (leave blank if no C-CDA or XDM Zip received). (For example: list the C-CDA sample filename, XDM Zip sample filename, or other sample filename from the DirectTrust payload archive, or specify a new filename if not in archive, and send the sample to admin@directtrust.org with the same filename; otherwise leave this field blank; no PHI in sample files, please).
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of DirectTrust.