Form #2 KID Application

KID APPLICATION KIT

October 3, 2012

CENTRAL DISTRIBUTOR

HCUP KID APPLICATION
The Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID) is available through
the HCUP Central Distributor under the auspices of the Agency for Healthcare Research and Quality
(AHRQ). The KID database excludes data elements that could directly or indirectly identify individuals.
Access to the files is open to users who sign a Data Use Agreement. Users must agree to use the
database for research and statistical purposes only and to make no attempts to identify individuals.
Directions to Complete the HCUP KID Application:
1. Print or type all responses. An electronic copy is available on request.
2. Complete Part I: Organization and/or Individual Requesting Use of the HCUP KID (page 3).
3. Complete Part II: Selection of HCUP KID (page 4).
4.

Determine the Total Payment Due and Select Payment Method (Part III, pages 5-6).

5. Read and sign the Indemnification Clause (Part IV, page 7).
6. Complete the online HCUP Data Use Agreement Training Course and provide your Certification
Code (Part V, page 8).
7. Read and sign the Data Use Agreement for HCUP Kids’ Inpatient Database (pages 9-12).
8. Submit the completed application (pages 3-12):
HCUP Central Distributor
Social & Scientific Systems, Inc.
th
8757 Georgia Avenue, 12 Floor
Silver Spring, MD 20910
Telephone: (866) 556-4287-toll free Fax: (866) 792-5313

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E-mail: [email protected]

HCUP KID Application

Part I: Organization and/or Individual Requesting Use of the HCUP KID
General Information:
Applicant Name:
Position/Title:
Organization (include Branch, Division,
Department):
Street Address:
City:

State:

Phone Number:

Fax:

Zip Code:

E-mail Address:

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Part II: Selection of HCUP KID
The price of the KID has been set to cover the full costs associated with disseminating it to data requesters. The
price includes labor costs related to handling inquiries, preparing data files, and copying documentation; and the
costs associated with materials and shipping.
Students may purchase any version of the KID at a discounted price. For specific price information, please see
the price sheet below. Students must demonstrate that they are in fact a student by providing: 1) a copy of a valid
student ID, OR 2) a letter from the registrar’s office, a professor, or program director verifying that they are in fact
a student.
If you have questions or want more information, please contact the HCUP Central Distributor by phone at (866)
556-4287 (toll-free), by fax at (866) 792-5313, or by e-mail at [email protected].

Database

Media/Structure

Price

KID, 2009

1 year of data on 1 DVD,
compressed files in ASCII format

‰ $ 350
‰ $ 50

All Others
Students

KID, 2006

1 year of data on 1 CD, compressed
files in ASCII format

‰ $ 200
‰ $ 20

All Others
Students

KID, 2003

1 year of data in 2-CD set,
compressed files in ASCII format

‰ $ 200
‰ $ 20

All Others
Students

KID, 2000

1 year of data in 2-CD set,
compressed files in ASCII format

‰ $ 200
‰ $ 20

All Others
Students

KID, 1997

1 year of data in 1-CD set,
compressed files in ASCII format

‰ $ 200
‰ $ 20

All Others
Students

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HCUP KID Application

Part III: Determine the Total Payment Due and Select Payment Method
Total Payment Due
If you need help determining the total payment due, submit the completed application (pages 3-12), without
payment, to the HCUP Central Distributor and request an invoice. An itemized invoice stating the total payment
due, including taxes for applicants in Maryland, will be faxed or e-mailed to you. Note that the HCUP Central
Distributor collects taxes only from applicants in Maryland. All other applicants are responsible for determining
tax liability and remitting taxes directly to state and local taxing authorities.
TOTAL PAYMENT DUE
KID Data Cost From Part II:

$_____________

Tax (MD applicants only):

$_____________

Total Payment Due:

$_____________

Orders will not be filled until the completed application and a purchase order or full payment have been
received.
Payment Methods
The HCUP Central Distributor accepts purchase orders, and payment may be made by major credit card, check,
or electronic funds' transfer.
Paying by Credit Card
Visa, MasterCard and American Express are accepted. Your credit card is not charged until the day your order is
shipped. A credit card receipt for your purchase is included with the order.
Credit card information is accepted only by toll-free Central Distributor fax, telephone or mail. PLEASE DO
NOT SEND CREDIT CARD INFORMATION BY E-MAIL. If you would like to fax or mail the information, complete
items 1 – 10 of the Credit Card Payment form on the next page and submit it with your itemized invoice or
completed application to the following address:
HCUP Central Distributor
Social & Scientific Systems, Inc.
th
8757 Georgia Avenue, 12 Floor
Silver Spring, MD 20910
Toll free Fax: 866-792-5313
If you prefer to provide your credit card information by telephone, please call toll-free at (866) 556-4287 between
9 a.m. and 5 p.m. Eastern Time.
Paying by Check
Checks should be made payable to Social & Scientific Systems, Inc. Mail a check for the total payment due with
your itemized invoice or completed application. The address is listed above.

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HCUP KID Application

Credit Card Payment Form: Fax, mail or telephone only—DO NOT SEND VIA E-MAIL.
To pay by credit card, complete items 1 – 10 of this form and submit it via the Central Distributor’s toll-free fax
(866-792-5313), toll-free telephone (866- 556-4287) or mail (see address on previous page).
1. Date:
2. Individual/Company Name:
3. Names On Credit Card:
Please list the names on the credit card exactly as they are shown on the card.

4. Type Of Credit Card:

MASTERCARD

VISA

AMERICAN EXPRESS

5. Amount:
6. Credit Card Number:
7. Expiration Date:
8. Credit Card Billing Address:

9. City, State & Zip Code:
10. Customer Signature:

For Office Use Only
Verbal Authorization For Signature:

Yes

No

Person Requesting Credit Card Processing: ___________________________________________________
Requester’s Phone Number And Extension: ___________________________________________________
Project Code Number: _____________________________________________________________________
Date Processed: ___________________________

Invoice Numbers Paid: ________________________

Project Code: ______________________________

_____________________________________________

Input By: __________________________________

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Part IV: Indemnification Clause

The Data Recipient (“Recipient”) shall, to the extent permitted by Federal and State law, indemnify and hold
Truven Health Analytics Inc. and its directors, officers, employees, agents, affiliates and subsidiaries harmless
from any and all losses, claims, damages, liabilities, costs and expenses (including, without limitation,
reasonable attorney’s fees and costs) arising out of any claim arising from any third parties, including but not
limited to any or some combination of the several States comprising the United States of America and/or the
Government of the United States of America, concerning Recipient’s use of the KID data provided by Truven
Health Analytics Inc. Further, Recipient agrees that Truven Health Analytics Inc. shall not be liable to Recipient
for any reason whatsoever arising out of the KID data or the Recipient’s use of the KID data.
Recipient certifies and warrants that it has made no representations to Truven Health Analytics Inc. concerning
any uses it (Recipient) intends to make of the KID data provided by to Truven Health Analytics Inc. under the
terms and conditions of Truven Health Analytics Inc. contract with the U.S. Department of Health and Human
Services, Agency for Healthcare Research and Quality. Further, Recipient agrees that no representation of
Recipient as to the Recipient’s intended use of the KID data was used to determine whether the Recipient’s
request to use KID data would be approved.

The Data Recipient (“Recipient”) shall, to the extent permitted by Federal and State law, indemnify and hold
Social & Scientific Systems, Inc. (SSS) and its directors, officers, employees, owners, and agents harmless
from any and all losses, claims, damages, liabilities, costs and expenses (including, without limitation,
reasonable attorney’s fees and costs) arising out of any claim arising from any third parties, including but not
limited to any or some combination of the several States comprising the United States of America and/or the
Government of the United States of America, concerning Recipient’s use of the KID data provided by SSS.
Further, Recipient agrees that SSS shall not be liable to Recipient for any reason whatsoever arising out of the
KID data or the Recipient’s use of the KID data.
Recipient certifies and warrants that it has made no representations to SSS concerning any uses it (Recipient)
intends to make of the KID data provided by SSS under the terms and conditions of its contract with the U.S.
Department of Health and Human Services, Agency for Healthcare Research and Quality. Further, Recipient
agrees that no representation of Recipient as to the Recipient’s intended use of the KID data was used to
determine whether the Recipient’s request to use KID data would be approved.

Signed:

KID Indemnification Clause

Date:

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Part V: HCUP Data Use Agreement Training

New Requirement: HCUP Data Use Agreement Training
Because of the sensitive nature of the data contained in the Healthcare Cost and Utilization Project
(HCUP) databases, there is a continued need to reinforce the safeguards and restrictions placed on use
of the data. All data purchasers and users of HCUP data must complete the HCUP Data Use Agreement
(DUA) Training Course. This course emphasizes the importance of data protection, helps to reduce the
risk of inadvertent violations, and describes your individual responsibility when using HCUP data. The
course will take approximately 15 minutes to complete and you will not be required to take it more than
once.
If you have not previously completed the HCUP DUA Training Course, please go to the HCUP-US
website at http://www.hcup-us.ahrq.gov/tech_assist/dua.jsp, complete the online HCUP DUA Training
Course, and enter the certification number at the end of the course in the space provided below.
HCUP DUA Training Course Certification Code : _______________________________________

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HCUP KID Application

DATA USE AGREEMENT for the
Kids’ Inpatient Database from the
Healthcare Cost and Utilization Project
Agency for Healthcare Research and Quality
This Data Use Agreement (“Agreement”) implements the data protections of the Health Insurance
Portability and Accountability Act (HIPAA) of 1996 (Public Law 104-191) and the Agency for Healthcare
Research and Quality (AHRQ) confidentiality statute. Any individual (“data recipient”) seeking to obtain or
use data in the Kids’ Inpatient Database (KID) from the Healthcare Cost and Utilization Project (HCUP)
maintained by the Center for Delivery, Organization, and Markets (CDOM) within AHRQ, must sign and
submit this Agreement to AHRQ or its agent before access to the KID may be granted.
In accordance with HIPAA, the KID may only be used or disclosed in the form of a limited data set, as
defined by the HIPAA Privacy Rule (45 CFR § 164.514(e)).
The AHRQ confidentiality statute, Section 924(c) of the Public Health Service Act (42 U.S.C. 299c-3(c)),
requires that data collected by AHRQ that identify individuals or establishments be used only for the
purpose for which they were supplied. Data supplied to AHRQ for HCUP and disclosed in limited data
set form are identifiable under the HIPAA Privacy Rule and are provided by the data sources only for
research, analysis, and aggregate statistical reporting. Therefore, data recipients may use HCUP data
only for these purposes.
No Identification of Persons–Any effort to determine the identity of any person contained in HCUP
databases (including but not limited to patients, physicians, and other health care providers), or to use the
information for any purpose other than for research, analysis, and aggregate statistical reporting, would
violate the AHRQ confidentiality statute, the conditions of this Agreement, and the HIPAA Privacy Rule.
Recipients of the data set are prohibited under the AHRQ confidentiality statute and the terms of this
Agreement from releasing, disclosing, publishing, or presenting any individually identifying information
obtained under this Agreement. AHRQ omits from the data set all direct identifiers that are required to be
excluded from limited data sets as defined by the HIPAA Privacy Rule. It may be possible in limited
situations, through deliberate technical analysis, and with outside information, to ascertain from the
limited data sets the identity of particular persons. Considerable harm could ensue if this were to occur.
Therefore, any attempts to identify individuals are prohibited and information that could identify individuals
directly or by inference must not be released or published. In addition, users of the data must not attempt
to contact individuals for any purpose, including verifying information supplied in the data set. Any
questions about the data must be referred exclusively to AHRQ.
Use of Establishment Identifiers–Section 924(c) of the Public Health Service Act (42 U.S.C. 299c-3(c))
also restricts the use of any information that permits the identification of establishments for purposes
other than those for which the information was originally supplied. Permission is obtained from the HCUP
data sources (state data organizations, hospital associations, and data consortia) to use the identification
of hospitals (when such identification appears in the data sets) for research, analysis, and aggregate
statistical reporting. This may include linking institutional information from outside data sets for these
purposes. Such purpose does not include the use of information in the data sets concerning individual
establishments for commercial or competitive purposes involving those individual establishments, or to
determine the rights, benefits, or privileges of establishments. Users of the data must not identify
establishments directly or by inference in disseminated material. In addition, users of the data must not
contact establishments for the purpose of verifying information supplied in the data set. Any questions

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Revised 11-7-11

about the data must be referred exclusively to AHRQ. Misuse of identifiable HCUP data about hospitals
would violate the AHRQ confidentiality statute and trigger its penalty provisions.
The undersigned gives the following assurances with respect to the KID data set:
•

I will not use and will prohibit others from using or disclosing the data set (or any part), except for
research, analysis, and aggregate statistical reporting, and only as permitted by this Agreement.

•

I will ensure that the data are kept in a secured environment and that only authorized users will have
access to the data.

•

I will not release or disclose, and will prohibit others from releasing or disclosing, any data that are
individually identifiable under the HIPAA Privacy Rule, or any information that identifies persons,
directly or indirectly, except as permitted under this Agreement and in accordance with the abovementioned AHRQ confidentiality statute.

•

I will not release or disclose information where the number of observations (i.e., individual discharge
records) in any given cell of tabulated data is less than or equal to 10.

•

I will not release or disclose, and will prohibit others from releasing or disclosing, the data set (or any
part) to any person who is not a member, agent, or contractor of the organization (specified below),
except with the approval of AHRQ.

•

I will require others employed in my organization (specified below), and any agents or contractors of
my organization, who will use or will have access to the data set, to sign a copy of this Agreement
(specifically acknowledging their agreement to abide by its terms) and I will submit those signed
Agreements to AHRQ or its agent before granting access.

•

I will not attempt to link, and will prohibit others from attempting to link, the discharge records of
persons in the data set with individually identifiable records from any other source.

•

I will not attempt to use and will prohibit others from using the data set to learn the identity of any
person included in the data set or to contact any such person for any purpose.

•

In accordance with the AHRQ confidentiality statute, I will not use and will prohibit others from using
the data set concerning individual establishments (1) for commercial or competitive purposes
involving those individual establishments; (2) to determine the rights, benefits, or privileges of
individual establishments; or (3) to report, through any medium, data that could identify, directly or by
inference, individual establishments.

•

When the identities of establishments are not provided in the data sets, I will not attempt to use and
will prohibit others from using the data set to learn the identity of any establishment.

•

I will not contact and will prohibit others from contacting establishments or persons in the data set to
question, verify, or discuss data in the HCUP databases.

•

I acknowledge that the KID contains data elements from proprietary restricted computer software (3M
APR-DRGs, HSS APS-DRGs, and Thomson Reuters Disease Staging) supplied by private vendors
to AHRQ for the sole purpose of supporting research and analysis with the KID. While I may freely
use these data elements in my research work using the KID, I agree that I will not use and will
prohibit others from using these proprietary data elements for any commercial purpose. In addition, I
will enter into a separate agreement with the appropriate organization or firm for the right to use such
proprietary data elements for commercial purposes. In particular, I agree not to disassemble,

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Revised 11-7-11

•

decompile, or otherwise reverse-engineer the proprietary software, and I will prohibit others from
doing so.
I will indemnify, defend, and hold harmless AHRQ and the data organizations that provide data to
AHRQ for HCUP from any or all claims and losses accruing to any person, organization, or other
legal entity as a result of violation of this Agreement. This provision applies only to the extent
permitted by Federal and State law.

•

I will make no statement and will prohibit others from making statements indicating or suggesting that
interpretations drawn are those of the data sources or AHRQ.

•

I will acknowledge in all reports based on these data that the source of the data is the “Kids’ Inpatient
Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research
and Quality.”

Safeguards. I agree to use appropriate safeguards to prevent use or disclosure of the data set other than
as permitted by this Agreement.
Permitted Access to Limited Data Set. I shall limit the use or receipt of the data set to the individuals who
require access in order to perform activities permitted by this Agreement. This Agreement must be
signed by all such individuals and submitted to AHRQ or its agent before access to the data set may be
granted.
Re-disclosure. I will not re-disclose (i.e., share) the data set (or any part), unless the individual who will
receive the data has agreed in writing to be bound by the same restrictions and conditions that apply to
me under this Agreement.
The HIPAA Privacy Rule. I agree not to use or disclose the data set in any manner that would violate the
HIPAA Privacy Rule if I were a covered entity under the Privacy Rule.
Agents and Contractors. I shall ensure that any agents, including contractors and subcontractors to
whom I provide the data set, agree in writing to be bound by the same restrictions and conditions that
apply to me with respect to the limited data set.
Reporting Violations of this Agreement. I agree to report any violations to AHRQ within twenty-four (24)
hours of becoming aware of any use or disclosure of the limited data set in violation of this Agreement or
applicable law.
Term, Breach, and Termination of this Agreement. This Agreement shall continue in full effect until the
data recipient has returned all copies of the data set to AHRQ. Any noncompliance by the data recipient
with the terms of this Agreement will be grounds for immediate termination of the Agreement if, at the sole
determination of AHRQ, the data recipient knew or should have known of such noncompliance and failed
to immediately take reasonable steps to remedy the noncompliance.
Reporting to the United States Department of Health and Human Services. If the data recipient fails to
remedy any breach or violation of this Agreement to the satisfaction of AHRQ, and if termination of the
Agreement is not feasible, AHRQ shall report the recipient’s breach or violation to the Secretary of the
United States Department of Health and Human Services, and the recipient agrees that he or she shall
not have or make any claims against AHRQ with respect to such report(s).

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I understand that this Agreement is requested by the United States Agency for Healthcare Research and
Quality to ensure compliance with its statutory confidentiality requirement. My signature indicates my
Agreement to comply with the above-stated requirements with the knowledge that any violation of the
AHRQ confidentiality statute is subject to a civil penalty of up to $10,000 under 42 U.S.C. 299c-3(d), and
that deliberately making a false statement about this or any matter within the jurisdiction of any
department or agency of the Federal Government violates 18 U.S.C. 1001 and is punishable by a fine of
up to $10,000 or up to five years in prison. Violators of this Agreement may also be subject to penalties
under state confidentiality statutes that apply to these data for particular states.
Signed:_____________________________________________

Date: _________________________

Print or Type Name of Data Recipient: ____________________________________________________
Title: _______________________________________________________________________________
Organization: ________________________________________________________________________
Address:____________________________________________________________________________
City: _____________________________________

State: ________

ZIP Code: ______________

Phone Number: ____________________________

Fax: ___________________________________

E-mail: _____________________________________________________________________________
The information above is maintained by AHRQ for the purpose of enforcement of this Agreement. This
information may also be used by AHRQ to create an HCUP mailing list. The mailing list allows AHRQ to
send users information such as notices about the release of new databases and errata when data errors
are discovered.
Note to Purchaser: Shipment of the requested data product will only be made to the person who signs
this Agreement, unless special arrangements that safeguard the data are made with AHRQ or its agent.
HCUP Central Distributor
Social & Scientific Systems, Inc.
8757 Georgia Avenue, 12th Floor
Silver Spring, MD 20910
E-mail: [email protected]

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Final Checklist:
9 Have you completed Part I and Part II of the application (pages 3-4)?
9 Have you determined the total payment due (page 5)?
9 If paying by check, have you enclosed a check payable to Social & Scientific Systems, Inc. for the
full amount due (page 5)?
9 If paying by credit card, have you completed and signed the credit card payment form (page 6)?
9

Have you read and signed the Indemnification Clause (page 7)?

9

Have you completed the online HCUP Data Use Agreement Training Course and provided your
Certification Code (page 8)?

9

Have you read and signed the “Data Use Agreement for HCUP KIDs’ Inpatient Database” (pages 912)?

9 Submit your application (pages 3-12) by fax or mail to the HCUP Central Distributor, SSS, Inc.
Contact information is listed on page 2.

For Internal Use Only:
Date Received:____________

DUA Signed/Dated:____________

Order Number:____________

Application Complete:____________

Payment Received:____________

Date Shipped: ____________

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