Form #3 NEDS Application

NEDS APPLICATION KIT

December 5, 2012

CENTRAL DISTRIBUTOR

HCUP NEDS APPLICATION
The Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS)
is available through the HCUP Central Distributor under the auspices of the Agency for Healthcare
Research and Quality (AHRQ). The NEDS database excludes data elements that could directly or
indirectly identify individuals, hospitals, or states. 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 analysis purposes
only and to make no attempts to identify individuals or hospitals.
For information on the NEDS, see the “Overview of the Nationwide Emergency Department Sample” at
http://www.hcup-us.ahrq.gov/nedsoverview.jsp.
Directions to Complete the HCUP NEDS 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 NEDS (page 2).
3. Complete Part II: Selection of HCUP NEDS (page 3).
4. Determine the Total Payment Due and Select Payment Method (Part III, page 4).
5. Read and sign the Indemnification Clause (Part IV, page 6).
6. Complete the online HCUP Data Use Agreement Training Course and provide your Certification
Code (Part V, page 7).
7. Read and sign the Data Use Agreement for Nationwide Emergency Department Sample (pages 8 11
8. Submit the completed application (pages 2 -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 E-mail: [email protected]

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HCUP NEDS Application

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

State:

Phone Number:

Fax:

Zip Code:

Internet Address:

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Part II: Selection of HCUP NEDS
The price of the NEDS 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 NEDS 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

NEDS, 2010

1 year of data on 1 DVD, compressed
files in comma-delimited format,
password protected

‰ $ 500.00 All Others
‰ $ 75.00 Students

NEDS, 2009

1 year of data on 1 DVD, compressed
files in comma-delimited format

‰ $ 500.00 All Others
‰ $ 75.00 Students

NEDS, 2008

1 year of data on 1 DVD, compressed
files in comma-delimited format

‰ $ 500.00 All Others
‰ $ 75.00 Students

NEDS, 2007

1 year of data on 1 DVD, compressed
files in comma-delimited format

‰ $ 500.00 All Others
‰ $ 75.00 Students

NEDS, 2006

1 year of data on 1 DVD, compressed
files in comma-delimited format

‰ $ 500.00 All Others
‰ $ 75.00 Students

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Part III: Determine the Total Payment Due and Select Payment Method
Total Payment Due
If you need help determining the payment due, submit the completed application (pages 2-12), 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
NEDS 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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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 NEDS
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 NEDS data or the Recipient’s
use of the NEDS 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 NEDS data provided by 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 NEDS data
was used to determine whether the Recipient’s request to use NEDS 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 NEDS
data provided by SSS. Further, Recipient agrees that SSS shall not be liable to Recipient for any reason
whatsoever arising out of the NEDS data or the Recipient’s use of the NEDS data.
Recipient certifies and warrants that it has made no representations to SSS concerning any uses it
(Recipient) intends to make of the NEDS 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 NEDS data was used to determine whether the Recipient’s request to use NEDS data would be
approved.

Signed:

NEDS Indemnification Clause

Date:

6

Revised 10/03/2012

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 NEDS Application

DATA USE AGREEMENT for the
Nationwide Emergency Department Sample
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 Nationwide
Emergency Department Sample (NEDS) 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 NEDS may be granted.
In accordance with HIPAA, the NEDS 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
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.

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The undersigned gives the following assurances with respect to the NEDS 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 above-mentioned 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 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.

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•

I will acknowledge in all reports based on these data that the source of the data is the “Nationwide Emergency
Department Sample (NEDS), 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 2 and 3)?
9 Have you determined the total payment due (page 4)?
9

If paying by check, have you enclosed a check payable to Social & Scientific Systems, Inc for the
full amount due (page 4)?

9

If paying by credit card, have you completed and signed the credit card payment form (page 5)?

9

Have you read and signed the Indemnification Clause (page 6)?

9

Have you completed the online HCUP Data Use Agreement Training Course and provided your
Certification Code (page 7)?

9

Have you read and signed the “Data Use Agreement for Nationwide Emergency Department
Sample”
(pages 8 -11)?

9 Submit your completed application (pages 2 -12) by fax or mail to the HCUP Central Distributor,
SSS, Inc. Contact information is listed on page 1.

For Internal Use Only:
Date Received:____________

DUA Signed/Dated:____________

Order Number:____________

Application Complete:____________

Payment Received:____________

Date Shipped: ____________

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