Data Request Form - JPS Health Network

Document technical information

Format docx
Size 154.0 kB
First found May 22, 2018

Document content analysis

Category Also themed
Language
English
Type
not defined
Concepts
no text concepts found

Persons

Organizations

Places

Transcript

JPS Health Network External Data Request Form
REQUEST DATE:
○ JPS or Acclaim Staff
JPS TICKET #:
REQUESTOR IDENTIFICATION AND CONTACT INFORMATION SECTION
○ UNT or TCU Faculty, Staff, or
○ External to JPS (contractor, vendor, non-UNT or -TCU
Student
researcher, etc.)
DATA NEEDS SECTION
○ LIMITED DATA SET IS NEEDED.
○ DE-IDENTIFIED DATA IS NEEDED (following HIPAA
regulations).
DATA USE SECTION
○ TPO * USE
○ CLINICAL RESEARCH USE:
○ DSRIP/1115 Waiver
○ OTHER (PLEASE EXPLAIN):
○ MARKETING USE
JPS IRB number:
Project:
○ FUND RAISING USE
JPS IRB approval date:
○ GOVT/PUBLIC HEALTH
Please attach approval letter,
REQUIRED REPORTING
protocol and data collection form
○ Limited Data Use Agreement currently in place (if so, please attach copy)
DISCLOSURE INTENT SECTION
HOW DO YOU PLAN TO USE THIS DATA?
○ PHI IS NEEDED.
○ JPS or Acclaim Staff, etc.
○ CLINICIANS EXTERNAL TO JPS
○ VENDOR OR BUSINESS
PARTNER
○ RESEARCHERS FROM OTHER
INSTITUTIONS
○ PUBLIC PRESENTATION OR PUBLICATION
(Attach Limited Use Data Agreement)
○ GOVT. OR PUBLIC AGENCY
TO BE COMPLETED BY REQUESTOR
NAME:
TITLE:
ADDRESS:
OFFICE PHONE:
ORGANIZATION:
ZIP:
CELL:
EMAIL:
CONTACT IF NOT SAME AS ABOVE
NAME:
TITLE:
ADDRESS:
OFFICE PHONE:
ORGANIZATION:
ZIP:
CELL:
EMAIL:
PURPOSE OF REQUEST:
* TPO: Treatment, Payment and Healthcare Operations
NOTE: WHEN REQUESTING PHI OR NON-SUMMARIZED PATIENT LEVEL DATA FOR RESEARCH PURPOSES, REQUESTOR MUST HAVE OBTAINED JPS IRB
APPROVAL PRIOR TO SUBMITTING THIS REQUEST. PLEASE ATTACH A COPY OF THE JPS IRB APPROVAL WHEN SUBMITTING THIS REQUEST.
JPS Health Network External Data Request Form
STATEMENT OF UNDERSTANDING/DATA USE AGREEMENT
DATA OBTAINED VIA THIS REQUEST MAY BE USED ONLY FOR THE PURPOSES STATED IN THIS APPLICATION AND ITS ACCOMPANYING
JPS IRB APPROVAL (IF REQUIRED). PATIENT CONTACT INFORMATION PROVIDED VIA THIS REQUEST MUST NOT BE RETAINED FOR
USE IN ANOTHER STUDY. THE PRINCIPAL INVESTIGATOR / REQUESTER OF THIS INFORMATION IS RESPONSIBLE FOR ANY MISUSE OF
THESE DATA. UNLESS EXPRESSLY APPROVED, RE-IDENTIFICATION AND/OR LINKING OF DE-IDENTIFIED DATA TO ANY OTHER
SOURCE IS PROHIBITED AND WILL BE CONSIDERED A BREACH OF SECURITY.
I ALSO UNDERSTAND THAT IN ACCORDANCE WITH JPS HEALTH NETWORK'S POLICY ON THE CONFIDENTIALITY OF PATIENT CARE
INFORMATION, ANY INAPPROPRIATE DISSEMINATION OF INFORMATION MAY RESULT IN DISCIPLINARY ACTION. I AGREE TO ABIDE
BY THESE STATEMENTS.
REQUESTER'S SIGNATURE
TITLE
ORGANIZATION
DATE
AUTHORIZED* SIGNATURE
TITLE
ORGANIZATION
DATE
*IF YOU ARE NOT THE PRINCIPAL INVESTIGATOR, YOU WILL NEED AN AUTHORIZED SIGNER.
SELECTION CRITERIA:
For questions regarding completion of this form: contact Kim Perkins at [email protected]
Submit completed form to: [email protected]
or
Deborah Baldwin, 1400 So. Main St., Office of the CIO, Fort Worth, Texas 76104
NOTE: WHEN REQUESTING PHI OR NON-SUMMARIZED PATIENT LEVEL DATA FOR RESEARCH PURPOSES, REQUESTOR MUST HAVE OBTAINED JPS IRB
APPROVAL PRIOR TO SUBMITTING THIS REQUEST. PLEASE ATTACH A COPY OF THE JPS IRB APPROVAL WHEN SUBMITTING THIS REQUEST.
3
JPS Health Network External Data Request Form
DE-IDENTIFIED DATA SET WILL NOT INCLUDE:
1.
Names
2.
All geographic subdivisions smaller than a state, including street address, city, county, precinct, ZIP code, and their equivalent
geocodes, except for the initial three digits of the ZIP code if, according to the current publicly available data from the Bureau
of the Census:
- The geographic unit formed by combining all ZIP codes with the same three initial digits contains more than 20,000 people;
and
- The initial three digits of a ZIP code for all such geographic units containing 20,000 or fewer people is changed to 000
3.
All elements of dates (except year) for dates that are directly related to an individual, including birth date, admission date,
discharge date, death date, and all ages over 89 and all elements of dates (including year) indicative of such age, except that
such ages and elements may be aggregated into a single category of age 90 or older
4.
Telephone numbers
5.
Vehicle identifiers and serial numbers, including license plate numbers
6.
Fax numbers
7.
Device identifiers and serial numbers
8.
Email addresses
9.
Web Universal Resource Locators (URLs)
10. Social security numbers
11. Internet Protocol (IP) addresses
12. Medical record numbers
13. Biometric identifiers, including finger and voice prints
14. Health plan beneficiary numbers
15. Full-face photographs and any comparable images
16. Account numbers
17. Any other unique identifying number, characteristic, or code
18. Certificate/license numbers
NOTE: WHEN REQUESTING PHI OR NON-SUMMARIZED PATIENT LEVEL DATA FOR RESEARCH PURPOSES, REQUESTOR MUST HAVE OBTAINED JPS IRB
APPROVAL PRIOR TO SUBMITTING THIS REQUEST. PLEASE ATTACH A COPY OF THE JPS IRB APPROVAL WHEN SUBMITTING THIS REQUEST.
3

Similar documents

×

Report this document