If you find anything in error, please contact Marc Nuar (email@example.com).
Application Technical Contact:
Application Support Model:
Application Administration Model:
Application Marketplace ID/Link:
|ServiceNow Request||Distribution Status & Date||Internal Review Status & Date||ePHI Indicator||Target User Base|
List current issues here. When an issue is resolved, document the resolution and date, and move the issue into the issue log.
Maintain a list of issues and their resolution.
Document the conditions under which the application would be subject to reapproval (e.g., collecting ePHI data when it did not previously).
|Review Request Date||Office of Technology Transfer Review||Legal Counsel Review (if applicable)||Marketing & Communications Review||Compliance & Regulatory Review||IT Security Review||LITS HIPAA Security Review (if applicable)|
Architecture Review (if applicable)
Approval artifacts and relevant documentation may be located here: (app Box folder link)