1. [INSERT THE NAME OF YOUR PILOT ORGANIZATION] INSERT DATE

2. [Insert Organization Name]: Introduction Participating Organization(s) »[insert] Point of contact(s) »[Insert Name + Title], [Insert Email] Background »[Any information relevant to patient choice and piloting] 2

3. [Insert Organization Name]: Business Drivers & Use Case What is the real world problem/challenge this pilot will help solve? How does this challenge align with The Patient Choice Technical Project Use Case scenarios? »Scenario 1: Provider pushes Consent Directive to Consent Directive Repository (PUSH) »Scenario 2: Provider pushes Consent Directive to HIE and Immunization Registry (PUSH) »Scenario 3: HIE Consent Directive Repository (PULL) »Scenario 4: HIE/Immunization Registry Consent Directive Repository (PULL) »Scenario 5: Hospital Consent Directive Repository (PULL) Are there alternative scenarios that you would intend to pilot? 3

4. [Insert Organization Name]: [Insert relevant use case scenario title] What is your high-level information flow? »Block diagram, sequence diagrams etc. »What components of the information flow currently exist and which will be new for the pilot? Describe your technical solution and implementation plan? »Architecture »Standards used 4

5. [Insert Organization Name]: Timeline & Resources Timeline »Projected Start Date: [Insert date] »Projected End Date: September 2016 »Dependencies/Major Milestones: [Insert date(s)] Resources »Available resources –staff, partnerships(business agreements) etc. »Resource constraints –Include possible solution/work-around Risks 5