Form #4 SID & SASD &SEDD Application

November 16, 2012
SID/SASD/SEDD APPLICATION KIT

CENTRAL DISTRIBUTOR
UNIFORM STATE APPLICATION
0B

Data Organizations participating in the Healthcare Cost and Utilization Project (HCUP) have agreed to
release their State Inpatient Databases (SID), State Ambulatory Surgery Databases (SASD), and State
Emergency Department Databases (SEDD) through a Central Distributor under the auspices of the
Agency for Healthcare Research and Quality (AHRQ). This uniform application was designed by the
participating Data Organizations to satisfy their requirements. As such, the information requested in
this application is for the Data Organizations. The information is not for AHRQ or the HCUP Central
Distributor. AHRQ and the HCUP Central Distributor are facilitating access to the SID, SASD and
SEDD, which are owned and regulated by the individual Data Organizations participating in HCUP.
The Data Organizations dictate which data elements may be released through the HCUP Central
Distributor. However, data elements in the SID, SASD, and SEDD are in a uniform HCUP format that
is consistent across all states and years of HCUP data.
Directions to Complete the Uniform State Application:
2B

1. Print or type all responses.
2. Complete all applicable parts of this application.
Part I Organization and/or Individual Requesting Use of the HCUP Databases (page 2)
Part II Intended Use of Data and Project Activities (page 3)
Part III Selection of HCUP Databases (page 5)
23H

24H

25H

3. Determine the Total Payment Due and Select Payment Method (Part IV, page 19).
26H

4. Read and sign the Indemnification Clause (Part V, page 21).
5. Complete the online HCUP Data Use Agreement Training Course and provide your Certification
Code (Part VI, page 22).
27H

6. If purchasing the SID, read and sign the Data Use Agreement for HCUP State Inpatient Databases
(Part VII, page 23).
28H

7. If purchasing the SASD, read and sign the Data Use Agreement for HCUP State Ambulatory
Surgery Databases (Part VIII, page 27).
29H

8. If purchasing the SEDD, read and sign the Data Use Agreement for HCUP State Emergency
Department Databases (Part IX, page 31).
30H

9. Submit the completed application (pages 2-35):
31H

HCUP Central Distributor
Social & Scientific Systems, Inc.
th
8757 Georgia Avenue, 12 Floor
Silver Spring, MD 20910
Telephone: (866) 556-4287 (toll free)

HCUP SID/SASD/SEDD (11/16/2012)

Fax: (866) 792-5313

1

E-mail: HCUPDistributor@AHRQ.gov

Uniform State Application

Part I: Organization and/or Individual Requesting Use of the HCUP Databases
3B

General Information:

Applicant Name:
Position/Title:
Organization (include Branch, Division, Department):
Street Address:
City:

State:

Phone Number:

Fax:

ZIP Code:

E-mail Address:

Type of Organization:
Check the one box that best describes your organization.
 University/college/teaching institution
 Government agency
 Managed care, insurer
 Healthcare provider
 Pharmaceutical, biotechnology, medical product firm
 Trade association, lobbying group, consortium
 Research organization, consultant
 Other (describe in space provided)

Check the one box that best characterizes the type of ownership of your organization.
 Not-for-profit
 For-profit

HCUP SID/SASD/SEDD (11/16/2012)

2

Uniform State Application

Part II: Intended Use of Data and Project Activities
4B

Describe the intended use of the data requested. Attach additional pages if necessary.
Include:


Brief description of project(s) and intended use of the data (e.g., clinical research, health
services research, analyses to address public policy issues, analyses to address private policy issues,
creating products or tools such as quality measurements, severity adjustment software, etc.)



Brief description of the subject area(s) that you plan to investigate (e.g., health outcomes,
quality, cost, utilization, access, markets, etc.)



Brief description of the potential uses of the final products that you may create using
the data (e.g., papers, reports, tools, analyses for public domain and/or internal use, etc.)

Please refer to Part VI “Data Use Agreement for HCUP State Inpatient Databases” (page 23), Part VII “Data Use
Agreement for HCUP State Ambulatory Surgery Databases” (page 27), and Part VIII “Data Use Agreement for
HCUP State Emergency Department Databases” (page 31) for complete descriptions of the acceptable uses of
the HCUP SID, SASD, and SEDD. In general, the HCUP SID, SASD, and SEDD are available for the purpose of
research and aggregate statistical reporting. Attempts to identify individuals are strictly prohibited. Information
that could identify individuals or establishments directly or by inference may not be released in disseminated
materials. The data may not be re-released in any form without prior approval of the participating Data
Organization(s).
32H

3H

34H

HCUP SID/SASD/SEDD (11/16/2012)

3

Uniform State Application

HCUP Request:
Check all boxes that describe the reasons for requesting the HCUP databases.


Research requires specific state(s).



Research requires variables only available in the selected states (e.g., encrypted patient ZIP Codes,
encrypted physician identifiers). Indicate variables below.

Other (describe in space provided)

HCUP SID/SASD/SEDD (11/16/2012)

4

Uniform State Application

Part III: Selection of HCUP Databases
5B

Section I. Select State Inpatient Databases (SID)

Mark boxes for the data you are requesting (see next page) and enter the total cost of requested data under
the column titled “Total.”
Please refer to the Databases section of the HCUP User Support Website (www.hcup-us.ahrq.gov) for
detailed information about the SID. Not all HCUP data elements are available from every state.
0H

The participating Data Organizations dictate the price of the data. Handling charges are already included.
Some Data Organizations offer a price discount to AHRQ Grant recipients, and Arizona currently offers a
discount to students.
If you are not sure if you qualify for the AHRQ Grantee discount, please refer to Section IV. AHRQ Grantee
(page 18).
Students may purchase the 2005-2011 Arizona SID for $35. 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.
HCUP Data Elements for Revisit Analyses
Two new HCUP data elements can be used in tandem to track sequential visits for a patient within a state
and across facilities and settings (inpatient, emergency department, ambulatory surgery) while adhering to
strict privacy guidelines:


VisitLink (http://www.hcup-us.ahrq.gov/db/vars/siddistnote.jsp?var=visitlink) is a synthetic person-level
identifier that has been verified against the patient’s date of birth and gender and examined for
completeness.



DaysToEvent (http://www.hcup-us.ahrq.gov/db/vars/siddistnote.jsp?var=daystoevent ) is a timing
variable that can be used to determine the days between hospital events for an individual. Actual dates
(admission, discharge or birth) are not needed.

1H

2H

These data elements are in two different formats, depending on the data year:


2003-2008: VisitLink and DaysToEvent are in a comma-separated values (CSV) supplemental file on
the data CDs or DVDs. The CSV file also contains the unique record identifier, KEY (http://www.hcupus.ahrq.gov/db/vars/siddistnote.jsp?var=key ), which must be used to merge revisit data with the
discharge files.
3H



2009 forward: VisitLink and DaysToEvent are included in the ASCII-format Core files.

Detailed documentation is provided at http://www.hcup-us.ahrq.gov/toolssoftware/revisit/revisit.jsp.
4H

In the price tables on the following pages, databases that include revisit data are identified with an
(R) to the right of the price, for example:  $ 35 (R).
If you have any questions or want information on other years of data or more sensitive data elements for a
state, please contact the HCUP Central Distributor by phone at (866) 556-4287 (toll free), fax at
(866) 792-5313 (toll free), or e-mail at HCUPDistributor@AHRQ.gov.
5H

HCUP SID/SASD/SEDD (11/16/2012)

5

Uniform State Application

State

HCUP SID Price Structure

1990

1991

1992

1993

1994

1995 - 1999

Arizona

All Applicants

Arkansas

All Applicants

California

All Applicants

Colorado

All Applicants

 $

255

 $

255

 $

255

 $

255

 $

255

See next page

Florida

All Applicants

 $

135

 $

135

 $

135

 $

135

 $

Hawaii

 $

35

Not Available
Not Available

Not-for-profit Affiliation

Not Available

For-profit Affiliation

Not Available

 $

35

Not Available
Not Available

Not Available
Not Available

 $

35

Not Available
Not Available

Not Available
Not Available

Iowa

All Applicants

Kentucky

All Applicants

Not Available

Not Available

Not Available

Non-profit/Educational

Not Available

Not Available

Commercial

Not Available

Not Available

Maine

 $

435

 $

435

 $

 $

35

Not Available
Not Available

Not Available
Not Available

 $

 $

35

See next page

Not Available

See next page

Not Available

See next page

135

See next page

Not Available

See next page

Not Available

See next page

 $

435

See next page

Not Available

Not Available

See next page

Not Available

Not Available

Not Available

See next page

Not Available

Not Available

Not Available

See next page

435

435

Maryland

All Applicants

 $

35

 $

35

 $

35

 $

35

 $

35

See next page

Massachusetts

All Applicants

 $

835

 $

835

 $

835

 $

835

 $

835

See next page

Michigan
Mississippi

Nebraska

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Others

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Students

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Others

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

AHRQ Grantee
(Complete Section IV, page 18)

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Total

35H

Nevada
New Jersey

All Applicants

New Mexico

All Applicants

 $

60

Not Available

AHRQ Grantee
(Complete Section IV, page 18)
Non-profit Research

 $

60

Not Available

 $

60

Not Available

 $

60

Not Available

 $

60

See next page

Not Available

See next page

 $

360

 $

360

 $

360

 $

360

 $

360

See next page

36H

New York

North Carolina

 $

360

 $

360

 $

360

 $

360

 $

360

See next page

Students

 $

185

 $

185

 $

185

 $

185

 $

185

See next page

All Others

 $

685

 $

685

 $

685

 $

685

 $

685

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Oregon

For-profit Affiliation--SEE
FOOTNOTE.

Not Available

Not Available

Not Available

Rhode Island

All Applicants

Not Available

Not Available

South Carolina

All Applicants

Not Available

Not-for-profit Affiliation

Not Available

For-profit Affiliation

South Dakota

Vermont

 $

235

See next page

Not Available

Not Available

See next page

Not Available

Not Available

Not Available

See next page

Not Available

Not Available

Not Available

Not Available

See next page

Not Available

Not Available

Not Available

Not Available

See next page

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Public, State/Federal Agency,
Academic Organization
Private Organization

Utah

 $

Washington

All Applicants

West Virginia

All Applicants

Wisconsin

All Applicants

 $

735

Not Available

 $

635

 $

735

Not Available

 $

635

 $

735

Not Available

 $

635

 $

235

735

Not Available

 $

635

 $

735

See next page

Not Available

See next page

 $

635

See next page

The Oregon Association of Hospitals and Health Systems only disseminates data to not-for-profit organizations through the HCUP Central
Distributor. For-profit applicants may discuss their data requirements with the association, whose contact information is on-line at
http://www.hcup-us.ahrq.gov/partners.jsp?SID

HCUP SID/SASD/SEDD (11/16/2012)

6

Uniform State Application

State

HCUP SID Price Structure

1995

1996

1997

1998

1999

2000 - 2004

Arizona

All Applicants

 $

Arkansas

All Applicants

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

California

All Applicants

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Colorado

All Applicants

 $

255

 $

255

 $

255

 $

255

 $

255

See next page

Florida

All Applicants

 $

140

 $

140

 $

140

 $

135

 $

135

See next page

Not-for-profit Affiliation

Not Available

 $

635

 $

635

 $

635

 $

635

See next page

For-profit Affiliation

Not Available

 $

835

 $

835

 $

835

 $

835

See next page

Not-for-profit Affiliation

 $

435

 $

435

 $

435

 $

435

 $

435

See next page

For-profit Affiliation

 $

435

 $

435

 $

435

 $

835

 $

835

See next page

All Applicants

Not Available

Not Available

See next page

Non-profit/Educational

Not Available

Not Available

Not Available

Not Available

 $

435

See next page

Commercial

Not Available

Not Available

Not Available

Not Available

 $

435

See next page

All Applicants

 $

35

 $

35

 $

35

 $

35

 $

35

See next page

Massachusetts All Applicants

 $

845

 $

845

 $

845

 $

835

 $

835

See next page

Not Available

Not Available

 $

560

See next page

Not Available

Not Available

 $

985

See next page

Hawaii
Iowa
Kentucky
Maine
Maryland

Michigan
Mississippi

Nebraska

35

 $

35

Not Available

 $

35

Not Available

 $

35

Not Available

 $

35

Not-for-profit Affiliation

Not Available

For-profit Affiliation

Not Available

Not Available

All Others

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Students

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Others

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not Available

TOTAL

See next page

AHRQ Grantee
(Complete Section IV, page 18)

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

New Jersey

All Applicants

 $

New Mexico

All Applicants

Not Available

37H

Nevada

70

 $

65

Not Available

 $

65

Not Available

 $

60

Not Available

60

See next page

Not Available

See next page

 $

AHRQ Grantee
(Complete Section IV, page 18)

 $

385

 $

385

 $

380

 $

360

 $

360

Non-profit Research

 $

385

 $

385

 $

380

 $

360

 $

360

See next page

Students

 $

185

 $

185

 $

185

 $

185

 $

185

See next page

All Others

 $

710

 $

710

 $

705

 $

685

 $

685

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

See next page

38H

New York

North Carolina

Not-for-profit Affiliation

 $

Oregon

For-profit Affiliation—SEE
FOOTNOTE.

Not Available

Rhode Island

All Applicants

Not Available

South Carolina

All Applicants

 $

South Dakota

785

485

 $

785

Not Available
Not Available

 $

485

 $

785

Not Available
Not Available

 $

485

Not Available
Not Available

 $

635

 $

785

Not Available

See next page

Not Available

 $

See next page

See next page

635

See next page

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not Available

Not Available

 $

Private Organization

Not Available

Not Available

 $ 1,535

Not-for-profit Affiliation

Not Available

Not Available

Not Available

For-profit Affiliation

Not Available

Not Available

Not Available

Washington

All Applicants

 $

West Virginia

All Applicants

Not Available

Wisconsin

All Applicants

 $

Vermont

785

Not-for-profit Affiliation
Public, State/Federal Agency,
Academic Organization

Utah

 $

735

635

 $

735

Not Available

 $

635

 $

785

735

Not Available

 $

635

 $

 $

785

See next page

 $ 1,535

 $ 1,535

See next page

Not Available

Not Available

See next page

Not Available

Not Available

See next page

 $

785

85

Not Available

 $

635

85

See next page

Not Available

See next page

 $

 $

635

See next page

The Oregon Association of Hospitals and Health Systems only disseminates data to not-for-profit organizations through the HCUP Central
Distributor. For-profit applicants may discuss their data requirements with the association, whose contact information is on-line at
http://www.hcup-us.ahrq.gov/partners.jsp?SID

HCUP SID/SASD/SEDD (11/16/2012)

7

Uniform State Application

State

HCUP SID Price Structure

2000

2001

2002

2003

2004

2005-2009

Arizona

All Applicants

 $

Arkansas

All Applicants

Not Available

Not Available

California

Government, Non-profit Research
or Educational Institution

Not Available

Not Available

All Others

Not Available

Not Available

Colorado

All Applicants

 $

355

 $

355

 $

Florida

All Applicants

 $

135

 $

135

 $

Not-for-profit Affiliation

 $

835

 $

835

 $

For-profit Affiliation

 $ 1,035

 $ 1,035

 $ 1,035

 $ 1,035

Not-for-profit Affiliation

 $

435

 $

435

 $

 $

 $

535

See next page

For-profit Affiliation

 $

835

 $

835

 $ 1,035

 $ 1,035

 $ 1,035

See next page

All Applicants

 $ 1,535

 $ 1,535

 $ 1,535

 $ 1,535

 $ 1,535

See next page

Non-profit/Educational

 $

435

 $

435

 $

435

 $

685

Not Available

See next page

Commercial

 $

435

 $

435

 $

435

 $ 1,335

Not Available

See next page

All Applicants

 $

35

 $

35

 $

35

 $

35

 $

35

See next page

Massachusetts All Applicants

 $

835

 $

835

 $

835

 $

835

 $

835

See next page

Not-for-profit Affiliation

 $

560

 $

560

 $

560

 $

560

 $

585

See next page

For-profit Affiliation

 $

985

 $

985

 $

985

 $ 1,535

 $ 1,535

See next page

All Others

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Students

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Others

Not Available

 $ 1,035

 $ 1,035

 $1,035 (R)

 $1,035 (R)

See next page

AHRQ Grantee
(Complete Section IV, page 18)

Not Available

 $

 $

535

 $ 535 (R)

 $ 535 (R)

See next page

Not-for-profit Affiliation

Not Available

Not Available

 $

285

 $ 285 (R)

 $ 285 (R)

See next page

For-profit Affiliation

Not Available

Not Available

 $

535

 $ 535 (R)

 $ 535 (R)

See next page

New Jersey

All Applicants

 $

 $

 $

60

 $

 $

New Mexico

All Applicants

Hawaii
Iowa
Kentucky
Maine
Maryland

Michigan
Mississippi

Nebraska

35

 $

35

535

 $

35

 $ 35 (R)

 $ 35 (R)

See next page

Not Available

Not Available

 $ 485 (R)

See next page

Not Available

 $ 235 (R)

 $ 35 (R)

See next page

 $ 235 (R)

 $ 235 (R)

See next page

355

 $

455

 $

455

See next page

135

 $

135

 $ 135 (R)

See next page

835

 $

835

 $

835

See next page

 $ 1,035

See next page

Not Available

535

535

TOTAL

39H

Nevada

60

Not Available

60

Not Available

Not Available

60

See next page

Not Available

60

Not Available

See next page

AHRQ Grantee
(Complete Section IV, page 18)

 $

360

 $

360

 $

360

 $ 360 (R)

 $ 385 (R)

See next page

Non-profit Research

 $

360

 $

360

 $

360

 $ 360 (R)

 $ 385 (R)

See next page

Students

 $

185

 $

185

 $

185

 $ 185 (R)

 $ 185 (R)

See next page

All Others

 $

685

 $

685

 $

685

 $ 685 (R)

 $ 735 (R)

See next page

Not-for-profit Affiliation

 $

535

 $

535

 $

535

 $ 535 (R)

 $ 535 (R)

See next page

For-profit Affiliation

 $ 1,535

 $ 1,535

 $ 1,535

 $1,535 (R)

 $1,535 (R)

See next page

Not-for-profit Affiliation

 $

 $

 $

 $

 $

785

See next page

Not Available

See next page

42H

New York

North Carolina

785

785

785

785

Oregon

For-profit Affiliation—See
FOOTNOTE

Rhode Island

All Applicants

Not Available

Not Available

 $

135

 $

135

 $

135

See next page

South Carolina

All Applicants

 $

 $

 $

635

 $

635

 $

635

See next page

South Dakota

Utah

Vermont

Not Available

635

Not Available

635

Not Available

Not Available

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

 $ 822 (R)

 $ 822 (R)

See next page

Public, State/Federal Agency,
Academic Organization

 $

Private Organization

 $ 1,535

 $ 1,610

 $ 1,610

 $1,610 (R)

 $1,610 (R)

See next page

Not-for-profit Affiliation

Not Available

 $

 $

 $

 $

555

See next page

785

 $

822

555

 $

822

555

555

For-profit Affiliation

Not Available

 $ 1,055

 $ 1,055

 $ 1,055

 $ 1,055

See next page

Washington

All Applicants

 $

85

 $

85

 $

85

 $ 85 (R)

 $ 85 (R)

See next page

West Virginia

All Applicants

 $

485

 $

485

 $

485

 $

510

 $

510

See next page

Wisconsin

All Applicants

 $

635

 $

635

 $

735

 $

735

 $

735

See next page

The Oregon Association of Hospitals and Health Systems only disseminates data to not-for-profit organizations through the HCUP Central
Distributor. For-profit applicants may discuss their data requirements with the association, whose contact information is on-line at
http://www.hcup-us.ahrq.gov/partners.jsp?SID

HCUP SID/SASD/SEDD (11/16/2012)

8

Uniform State Application

State

HCUP SID Price Structure

2005

2006

2007

2008

2009

2010-2011

Students

 $ 35 (R)

 $ 35 (R)

 $ 35 (R)

 $

35

 $

35

See next page

Non-profit/Educational

 $135 (R)

 $135 (R)

 $135 (R)

 $

135

 $

135

See next page

For-profit Affiliation

 $335 (R)

 $335 (R)

 $335 (R)

 $

335

 $

335

See next page

Arkansas

All Applicants

 $485 (R)

 $485 (R)

 $485 (R)

 $485 (R)

 $485 (R)

See next page

California

Government, Non-profit Research
or Educational Institution
All Others

 $ 35 (R)

 $ 35 (R)

 $ 35 (R)

 $ 35 (R)

 $ 35 (R)

See next page

 $235 (R)

 $235 (R)

 $235 (R)

 $235 (R)

 $235 (R)

See next page

Colorado

All Applicants

 $

 $

 $

 $

 $

575

See next page

Florida

All Applicants

 $135 (R)

 $135 (R)

 $135 (R)

 $135 (R)

 $135 (R)

See next page

Not-for-profit Affiliation

 $

 $835 (R)

 $835 (R)

 $835 (R)

 $835 (R)

See next page

For-profit Affiliation

 $ 1,035

 $1,035(R)

 $1,035(R)

 $1,035(R)

 $1,235(R)

See next page

Not-for-profit Affiliation

 $

 $

 $

 $

 $

585

See next page

For-profit Affiliation

 $ 1,035

 $ 1,135

 $ 1,135

 $ 1,135

 $ 1,135

See next page

All Applicants

 $ 1,535

 $ 1,535

 $ 1,535

 $ 1,535

 $ 1,535

See next page

Non-profit/Educational

Not Available

 $

 $

 $

 $

685

See next page

Commercial

Not Available

 $ 1,335

 $ 1,335

 $ 1,335

 $ 1,335

See next page

All Applicants

 $

35

 $

35

 $

35

 $

35

 $

35

See next page

Massachusetts All Applicants

 $

835

 $

835

 $

835

 $

835

 $

835

See next page

Not-for-profit Affiliation

 $

585

 $

585

 $

585

 $

585

 $

585

See next page

For-profit Affiliation

 $ 1,535

 $ 1,535

 $ 1,535

 $ 1,535

 $ 1,535

See next page

All Others

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Students

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Others

 $1,035(R)

 $1,035(R)

 $1,035(R)

 $1,035(R)

 $1,035(R)

See next page

AHRQ Grantee
(Complete Section IV, page 18)
Not-for-profit Affiliation

 $535 (R)

 $535 (R)

 $535 (R)

 $535 (R)

 $535 (R)

See next page

 $435 (R)

 $435 (R)

 $435 (R)

 $

435

 $

435

See next page

Arizona

Hawaii
Iowa
Kentucky
Maine
Maryland

Michigan
Mississippi
Nebraska

41H

Nevada

515

835

535

515

585

685

515

585

685

515

585

685

For-profit Affiliation

 $835 (R)

 $835 (R)

 $835 (R)

 $

835

 $

835

See next page

New Jersey

All Applicants

 $

 $

 $

 $

60

 $

60

See next page

New Mexico

All Applicants

Not Available

Not Available

Not Available

Not Available

 $ 485 (R)

See next page

AHRQ Grantee
(Complete Section IV, page 18)
Non-profit Research

 $385 (R)

 $385 (R)

 $385 (R)

 $385 (R)

 $ 385 (R)

See next page

 $385 (R)

 $385 (R)

 $385 (R)

 $385 (R)

 $ 385 (R)

See next page

Students

 $185 (R)

 $185 (R)

 $185 (R)

 $185 (R)

 $ 185 (R)

See next page

All Others

 $735 (R)

 $735 (R)

 $735 (R)

 $735 (R)

 $ 735 (R)

See next page

Not-for-profit Affiliation

 $535 (R)

 $535 (R)

 $535 (R)

 $535 (R)

 $ 535 (R)

See next page

For-profit Affiliation

 $1,535(R)

 $1,535(R)

 $1,535(R)

 $1,535(R)

 $1,535(R)

See next page

Not-for-profit Affiliation

 $

 $

 $

 $

 $

See next page

42H

New York

North Carolina
Oregon

60

785

60

785

60

785

785

785

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Rhode Island

For-profit Affiliation—SEE
FOOTNOTE.
All Applicants

 $

135

 $

135

 $

135

 $

135

 $

135

See next page

South Carolina

All Applicants

 $

635

 $

635

 $

635

 $

635

 $

735

See next page

Not-for-profit Affiliation

Not Available

Not Available

 $

785

 $

785

 $

785

See next page

For-profit Affiliation

Not Available

Not Available

 $ 1,235

 $ 1,235

 $ 1,235

See next page

Public, State/Federal Agency,
Academic Organization
Private Organization

 $822 (R)

 $822 (R)

 $822 (R)

 $822 (R)

 $822 (R)

See next page

 $1,610(R)

 $1,610(R)

 $1,610(R)

 $1,610(R)

 $1,610(R)

See next page

Not-for-profit Affiliation

 $

 $

 $

 $

 $

685

See next page

For-profit Affiliation

 $ 1,255

 $ 1,255

 $ 1,255

 $ 1,255

 $ 1,335

See next page

Washington

All Applicants

 $ 85 (R)

 $ 85 (R)

 $ 85 (R)

 $ 85 (R)

 $ 85 (R)

See next page

West Virginia

All Applicants

 $

510

 $

510

 $

510

 $

510

 $

510

See next page

Wisconsin

All Applicants

 $

835

 $

835

 $

835

 $

835

 $

835

See next page

South Dakota
Utah
Vermont

655

655

655

655

TOTAL

The Oregon Association of Hospitals and Health Systems only disseminates data to not-for-profit organizations through the HCUP Central
Distributor. For-profit applicants may discuss their data requirements with the association, whose contact information is on-line at
http://www.hcup-us.ahrq.gov/partners.jsp?SID

HCUP SID/SASD/SEDD (11/16/2012)

9

Uniform State Application

State

HCUP SID Price Structure

2010

2011

Students

 $

35

 $

35

Non-profit/Educational

 $

135

 $

135

For-profit Affiliation

 $

335

 $

335

All Applicants
Government, Non-profit Research or Educational
Institution
All Others

 $485 (R)

Not Available

 $ 35 (R)

 $ 35 (R)

 $235 (R)

 $235 (R)

Colorado

All Applicants

 $

 $

Florida

All Applicants

 $135 (R)

Not Available

Not-for-profit Affiliation

 $835 (R)

Not Available

For-profit Affiliation

 $1,235(R)

Not Available

Not-for-profit Affiliation

 $ 585(R)

Not Available

For-profit Affiliation

 $1,135(R)

Not Available

All Applicants

 $ 1,535

Not Available

Non-profit/Educational

Not Available

Not Available

Commercial

Not Available

Not Available

Maryland

All Applicants

 $

35

 $

Massachusetts

All Applicants

 $

835

Not Available

Not-for-profit Affiliation

 $

585

Not Available

For-profit Affiliation

 $ 1,535

Not Available

All Others

 $ 1,435

Not Available

Students

 $

Not Available

All Others
AHRQ Grantee
(Complete Section IV, page 18)
Not-for-profit Affiliation

 $1,035(R)

Not Available

 $535 (R)

Not Available

 $

435

Not Available

For-profit Affiliation

 $

835

Not Available

New Jersey

All Applicants

 $

60

Not Available

New Mexico

All Applicants
AHRQ Grantee
(Complete Section IV, page 18)
Non-profit Research

 $ 485 (R)

Not Available

 $ 385 (R)

Not Available

 $ 385 (R)

Not Available

Students

 $ 185 (R)

Not Available

All Others

 $ 735 (R)

Not Available

Not-for-profit Affiliation

 $ 535 (R)

Not Available

For-profit Affiliation

 $1,535(R)

Not Available

Not-for-profit Affiliation

 $

 $

Arizona
Arkansas
California

Hawaii
Iowa
Kentucky
Maine

Michigan
Mississippi

Nebraska

575

235

TOTAL

575

35

41H

Nevada

42H

New York

North Carolina
Oregon

785

785

For-profit Affiliation—SEE FOOTNOTE.

Not Available

Not Available

Rhode Island

All Applicants

 $

135

Not Available

South Carolina

All Applicants

 $

735

 $

Not-for-profit Affiliation

 $

785

Not Available

For-profit Affiliation

 $ 1,235

Not Available

Public, State/Federal Agency, Academic Organization

 $1,610(R)

Not Available

Private Organization

 $3,185(R)

Not Available

Not-for-profit Affiliation

 $

685

Not Available

For-profit Affiliation

 $ 1,335

Not Available

Washington

All Applicants

 $ 85 (R)

 $ 85 (R)

West Virginia

All Applicants

 $

510

Not Available

Wisconsin

All Applicants

 $

835

 $

South Dakota
Utah
Vermont

735

835

TOTAL DATA COST: Calculate total cost for all data requested.
See Part IV (page 43H19) for instructions on determining the total payment due:
The Oregon Association of Hospitals and Health Systems only disseminates data to not-for-profit organizations through the HCUP Central
Distributor. For-profit applicants may discuss their data requirements with the association, whose contact information is on-line at
http://www.hcup-us.ahrq.gov/partners.jsp?SID

HCUP SID/SASD/SEDD (11/16/2012)

10

Uniform State Application

Section II. Select State Ambulatory Surgery Databases (SASD)
Mark boxes for the data you are requesting. Please refer to the Databases section of the HCUP User
Support Website (www.hcup-us.ahrq.gov) for detailed information about the SASD. Not all HCUP data
elements are available from every state.
6H

The participating Data Organizations dictate the price of the data. Handling charges are already included.
Some Data Organizations offer a price discount to AHRQ Grant recipients. If you are not sure if you
qualify for this discount, please refer to Section IV. AHRQ Grantee (page 18). Enter the total cost of
requested data under the column titled “Total.”
HCUP Data Elements for Revisit Analyses
Two new HCUP data elements can be used in tandem to track sequential visits for a patient within a state
and across facilities and settings (inpatient, emergency department, ambulatory surgery) while adhering to
strict privacy guidelines:


VisitLink (http://www.hcup-us.ahrq.gov/db/vars/siddistnote.jsp?var=visitlink) is a synthetic personlevel identifier that has been verified against the patient’s date of birth and gender and examined
for completeness.



DaysToEvent (http://www.hcup-us.ahrq.gov/db/vars/siddistnote.jsp?var=daystoevent ) is a timing
variable that can be used to determine the days between hospital events for an individual. Actual
dates (admission, discharge or birth) are not needed.

7H

8H

These data elements are in two different formats, depending on the data year:


2003-2008: VisitLink and DaysToEvent are in a comma-separated values (CSV) supplemental
file on the data CDs or DVDs. The CSV file also contains the unique record identifier, KEY
(http://www.hcup-us.ahrq.gov/db/vars/siddistnote.jsp?var=key ), which must be used to merge
revisit data with the discharge files.
9H



2009 forward: VisitLink and DaysToEvent are included in the ASCII-format Core files.

Detailed documentation is provided at http://www.hcup-us.ahrq.gov/toolssoftware/revisit/revisit.jsp.
10H

In the price tables on the following pages, databases that include revisit data are identified with an
(R) to the right of the price, for example:  $ 35 (R).
If you have questions or want information on other years of data or more sensitive data elements for a
state, please contact the HCUP Central Distributor by phone at (866) 556-4287 (toll free), fax at (866) 7925313 (toll free), or e-mail at HCUPDistributor@AHRQ.gov.
1H

HCUP SID/SASD/SEDD (11/16/2012)

11

Uniform State Application

State

SASD Price Structure

1997

1998

1999

2000

2001

2002

2003

2004

2005-2001

Government, Non-profit
Research or Educational
Institution

California

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Others

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Colorado

All Applicants

 $

330

 $

330

 $

330

 $

330

 $

330

 $

355

 $

355

 $

355

See next page

Florida

All Applicants

 $

140

 $

135

 $

135

 $

135

 $

135

 $

135

 $

135

 $ 135(R)

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

 $

535

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

$

1,035

See next page

All Applicants

Not Available

Not Available

Not Available

 $

1,535

 $

1,535

 $

1,535

 $

1,535

 $

1,535

See next page

Non-profit/Educational

Not Available

Not Available

 $

435

 $

435

 $

435

 $

435

 $

435

Not Available

See next page

Commercial

Not Available

Not Available

 $

1,035

 $

1,035

 $

1,035

 $

1,035

 $

1,035

Not Available

See next page

All Applicants

 $

 $

 $

35

 $

35

 $

35

 $

35

 $

35

 $

35

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

 $

560

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

 $

985

See next page

All Others

$1,035(R)

 $ 1,035(R)

See next page

 $ 535(R)

 $ 535(R)

See next page

 $

 $

60

See next page

Iowa
Kentucky
Maine
Maryland
Michigan

Nebraska

35

35

Not Available

Not Available

Not Available

Not Available

 $

1,035

 $

1,035

AHRQ Grantee (Complete
Section IV, page 18)

Not Available

Not Available

Not Available

Not Available

 $

535

 $

535

All Applicants

4H

New Jersey

 $

60

 $

60

 $

60

 $

60

 $

60

 $

60

AHRQ Grantee(Complete
Section IV, page 18)

60

 $

260

 $

260

 $

260

 $

260

 $

260

 $

260

 $ 260(R)

 $ 285(R)

See next page

Non-profit Research

 $

260

 $

260

 $

260

 $

260

 $

260

 $

260

 $ 260(R)

 $ 285(R)

See next page

Students

 $

135

 $

135

 $

135

 $

135

 $

135

 $

135

 $ 135(R)

 $ 135(R)

See next page

All Others

 $

485

 $

485

 $

485

 $

485

 $

485

 $

485

 $ 485(R)

 $ 535(R)

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

 $

535

 $

535

 $

535

 $ 535(R)

 $ 535(R)

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

 $

1,535

 $

1,535

 $

1,535

 $ 1,535(R)

 $ 1,535(R)

See next page

Oregon

All Applicants

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

South Carolina

All Applicants

Not Available

Not Available

Not Available

 $

747

 $

747

 $

747

$

$

747

See next page

Utah

Public, State/Federal
Agency, Academic
Organization

 $

 $

785

 $

785

 $

785

 $

822

 $

822

 $ 822(R)

 $ 822(R)

See next page

Private Organization

 $ 1,535

 $ 1,535

 $

1,535

 $

1,535

 $

1,610

 $

1,610

 $1,610(R)

 $1,610(R)

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

 $

555

 $

555

 $

555

 $

555

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

 $

1,055

 $

1,055

 $

1,055

 $

1,055

See next page

All Applicants

Not Available

 $

 $

 $

 $

535

 $

635

 $

735

 $

735

See next page

45H

New York

North Carolina

Vermont
Wisconsin

HCUP SID/SASD/SEDD (11/16/2012)

785

535

535

12

535

747

Uniform State Application

State

SASD Price Structure

2004

2005

2006

2007

2008

2009

California

Government, Non-profit
Research or Educational
Institution

Not Available

 $ 35(R)

 $ 35(R)

 $ 35(R)

 $ 35(R)

 $ 35(R)

 $ 35(R)

 $ 35(R)

All Others

Not Available

 $ 235(R)

 $ 235(R)

 $ 235(R)

 $ 235(R)

 $ 235(R)

 $ 235(R)

 $ 235(R)

Colorado

All Applicants

 $

 $

 $

 $

 $

 $

 $

435

 $ 435

Florida

All Applicants

 $ 135(R)

 $ 135(R)

 $ 135(R)

 $ 135(R)

 $ 135(R)

 $ 135(R)

 $ 135(R)

Not Available

Not-for-profit Affiliation

 $

535

 $

535

 $

585

 $

585

 $

585

 $

585

 $ 585(R)

Not Available

For-profit Affiliation

$

1,035

$

1,035

$

1,135

$

1,135

$

1,135

$

1,135

 $ 1,135(R)

Not Available

All Applicants

 $

1,535

 $

1,535

 $

1,535

 $

1,535

 $

1,535

 $

1,535

 $

1,535

Not Available

Non-profit/Educational

Not Available

Not Available

 $

1,135

 $

1,135

 $

1,135

 $

1,135

Not Available

Not Available

Commercial

Not Available

Not Available

 $

2,635

 $

2,635

 $

2,635

 $

2,635

Not Available

Not Available

All Applicants

 $

35

 $

35

 $

35

 $

35

 $

35

 $

35

 $

 $

Not-for-profit Affiliation

 $

560

 $

585

 $

585

 $

585

 $

585

 $

585

 $

585

Not Available

For-profit Affiliation

 $

985

 $

1,535

 $

1,535

 $

1,535

 $

1,535

 $

1,535

 $

1,535

Not Available

All Others

Iowa
Kentucky
Maine
Maryland
Michigan

Nebraska

355

395

395

395

395

2010

435

2011

35

TOTAL

35

 $ 1,035(R)

 $ 1,035(R)

 $ 1,035(R)

 $ 1,035(R)

 $ 1,035(R)

 $ 1,035(R)

 $ 1,035(R)

Not Available

AHRQ Grantee (Complete
Section IV, page 18)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

Not Available

All Applicants

 $

 $

 $

 $

 $

 $

 $

60

Not Available

4H

New Jersey

60

60

60

60

60

60

AHRQ Grantee(Complete
Section IV, page 18)

 $ 285(R)

 $ 285(R)

 $ 285(R)

 $ 285(R)

 $ 285(R)

 $ 285(R)

 $ 285(R)

Not Available

Non-profit Research

 $ 285(R)

 $ 285(R)

 $ 285(R)

 $ 285(R)

 $ 285(R)

 $ 285(R)

 $ 285(R)

Not Available

Students

 $ 135(R)

 $ 135(R)

 $ 135(R)

 $ 135(R)

 $ 135(R)

 $ 135(R)

 $ 135(R)

Not Available

All Others

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

Not Available

Not-for-profit Affiliation

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

Not Available

For-profit Affiliation

 $ 1,535(R)

 $ 1,535(R)

 $ 1,535(R)

 $ 1,535(R)

 $ 1,535(R)

 $ 1,535(R)

 $ 1,535(R)

Not Available

Oregon

All Applicants

Not Available

Not Available

Not Available

Not Available

Not Available

Not Available

$

585

Not Available

South Carolina

All Applicants

$

$

$

$

$

$

$

935

$

Utah

Public, State/Federal
Agency, Academic
Organization

 $ 822(R)

 $ 822(R)

 $ 822(R)

 $ 822(R)

 $ 822(R)

Private Organization

 $1,610(R)

 $1,610(R)

 $1,610(R)

 $1,610(R)

Not-for-profit Affiliation

 $

555

 $

655

 $

655

 $

655

For-profit Affiliation

 $

1,055

 $

1,255

 $

1,255

 $

All Applicants

 $

735

 $

835

 $

835

 $

45H

New York

North Carolina

Vermont
Wisconsin

HCUP SID/SASD/SEDD (11/16/2012)

747

747

747

13

747

747

935

935

 $1,610(R)

Not Available

Not Available

 $ 1,610(R)

 $3,185(R)

Not Available

Not Available

 $

655

 $

685

 $

685

Not Available

1,255

 $

1,255

 $

1,335

 $

1,335

Not Available

835

 $

835

 $

835

 $

835

 $ 835

Uniform State Application

Section III. Select State Emergency Department Databases (SEDD)
Mark boxes for the data you are requesting (see next page) and enter the total cost of requested data
under the column titled “Total”.
Please refer to the Databases section of the HCUP User Support Website (www.hcup-us.ahrq.gov) for
detailed information about the SEDD. Importantly, the SEDD contain only emergency department visits
that do not result in hospitalizations. To complete an analysis on all emergency department visits,
researchers should purchase the SEDD and the SID. Not all HCUP data elements are available from
every state.
12H

The participating Data Organizations dictate the price of the data. Handling charges are already included.
Some Data Organizations offer a price discount to AHRQ Grant recipients, and Arizona currently offers a
discount to students.
If you are not sure if you qualify for the AHRQ Grantee discount, please refer to Section IV. AHRQ
Grantee (page 18).
Students may purchase the 2005-2011 Arizona SEDD for $35. 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.
HCUP Data Elements for Revisit Analyses
Two new HCUP data elements can be used in tandem to track sequential visits for a patient within a state
and across facilities and settings (inpatient, emergency department, ambulatory surgery) while adhering to
strict privacy guidelines:


VisitLink (http://www.hcup-us.ahrq.gov/db/vars/siddistnote.jsp?var=visitlink) is a synthetic personlevel identifier that has been verified against the patient’s date of birth and gender and examined
for completeness.



DaysToEvent (http://www.hcup-us.ahrq.gov/db/vars/siddistnote.jsp?var=daystoevent ) is a timing
variable that can be used to determine the days between hospital events for an individual. Actual
dates (admission, discharge or birth) are not needed.

13H

14H

These data elements are in two different formats, depending on the data year:


2003-2008: VisitLink and DaysToEvent are in a comma-separated values (CSV) supplemental
file on the data CDs or DVDs. The CSV file also contains the unique record identifier, KEY
(http://www.hcup-us.ahrq.gov/db/vars/siddistnote.jsp?var=key ), which must be used to merge
revisit data with the discharge files.
15H



2009 forward: VisitLink and DaysToEvent are included in the ASCII-format Core files.

Detailed documentation is provided at http://www.hcup-us.ahrq.gov/toolssoftware/revisit/revisit.jsp.
16H

In the price tables on the following pages, databases that include revisit data are identified with an
(R) to the right of the price, for example:  $ 35 (R).
If you have any questions or want information on other years of data or more sensitive data elements for a
state, please contact the HCUP Central Distributor by phone at (866) 556-4287 (toll-free), fax at (866)
792-5313 (toll free), or e-mail at HCUPDistributor@AHRQ.gov.
17H

HCUP SID/SASD/SEDD (11/16/2012)

14

Uniform State Application

State

1999

2000

2001

2002

2003

2004-2008

Students

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Non-profit/Educational

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Government, Non-profit Research
or Educational Institution

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Others

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Applicants

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

 $

835

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

 $ 1,035

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Applicants

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Non-profit/Educational

 $ 1,135

 $ 1,135

 $ 1,135

 $ 1,135

 $ 1,135

See next page

Commercial

 $ 2,635

 $ 2,635

 $ 2,635

 $ 2,635

 $ 2,635

See next page

Maryland

All Applicants

 $

 $

 $

35

 $

35

 $

35

See next page

Massachusetts

All Applicants

Not Available

Not Available

Not Available

 $

835

 $

835

See next page

All Others

Not Available

Not Available

 $ 1,035

 $ 1,035

 $ 1,035(R)

See next page

AHRQ Grantee
(Complete Section IV, page 46H18)

Not Available

Not Available

 $

 $

535

 $ 535(R)

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Applicants

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

AHRQ Grantee(Complete Section IV,
page 18)

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Non-profit Research

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Students

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Others

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Rhode Island

All Applicants

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

South Carolina

All Applicants

Not Available

 $ 1,889

 $ 1,889

 $ 1,889

$

1,889

See next page

Public, State/Federal Agency,
Academic Organization

Not Available

 $

 $

 $

830

 $ 830(R)

See next page

Private Organization

Not Available

 $ 1,630

 $ 1,630

 $ 1,630

 $1,630(R)

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

 $

 $

555

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

 $ 1,055

 $ 1,055

See next page

All Applicants

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

Arizona

California
Florida
Hawaii

Iowa
Kentucky
Maine

Nebraska

Nevada
New Jersey

HCUP SEDD Price Structure

35

35

535

TOTAL

45H

New York

North Carolina

Utah

Vermont
Wisconsin

HCUP SID/SASD/SEDD (11/16/2012)

830

15

830

555

Uniform State Application

State

Arizona

California

Florida
Hawaii

Iowa
Kentucky
Maine

HCUP SEDD Price Structure

2004

2005

2006

2007

2008

2009-2011

Students

Not Available

 $ 35(R)

 $ 35(R)

 $ 35(R)

 $

35

See next page

Non-profit/Educational

Not Available

 $135(R)

 $135(R)

 $135(R)

 $

135

See next page

For-profit Affiliation

Not Available

 $335(R)

 $335(R)

 $335(R)

 $

335

See next page

Government, Non-profit
Research or Educational
Institution

Not Available

 $ 35(R)

 $ 35(R)

 $ 35(R)

 $ 35(R)

See next page

All Others

Not Available

 $235(R)

 $235(R)

 $235(R)

 $235(R)

See next page

All Applicants

Not Available

 $135(R)

 $135(R)

 $135(R)

 $135(R)

See next page

 $

 $835(R)

 $835(R)

 $835(R)

See next page

Not-for-profit Affiliation

 $

For-profit Affiliation

 $ 1,035

 $ 1,035

 $1,035(R)  $1,035(R)  $1,035(R) See next page

Not-for-profit Affiliation

 $

 $

 $

For-profit Affiliation

 $ 1,035

 $ 1,035

 $ 1,135

All Applicants

Not Available

Not Available

Non-profit/Educational

Not Available

Commercial

Not Available

835

535

835

 $

 $

585

See next page

 $ 1,135

 $ 1,135

See next page

Not Available

Not Available

 $ 1,535

See next page

Not Available

 $ 1,135

 $ 1,135

 $ 1,135

See next page

Not Available

 $ 2,635

 $ 2,635

 $ 2,635

See next page

 $

 $

 $

See next page

535

585

585

Maryland

All Applicants

 $

Massachusetts

All Applicants

 $ 835

 $ 835

 $ 835

 $ 835

 $ 835

See next page

All Others

 $1,035(R)

 $1,035(R)

 $1,035(R)

 $1,035(R)

 $1,035(R)

See next page

AHRQ Grantee
(Complete Section IV, page 46H18)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

 $ 535(R)

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

Not Available

Not Available

See next page

All Applicants

 $

 $

 $

60

 $

60

 $

60

See next page

AHRQ Grantee(Complete Section IV,
page 18)

Not Available

Not Available

$

535

$

535

$

535

See next page

Non-profit Research

Not Available

Not Available

$

535

$

535

$

535

See next page

Students

Not Available

Not Available

$

285

$

285

$

285

See next page

All Others

Not Available

Not Available

$

1,035

$

1,035

$

1,035

See next page

Not-for-profit Affiliation

Not Available

Not Available

Not Available

 $ 535(R)

 $ 535(R)

See next page

For-profit Affiliation

Not Available

Not Available

Not Available

 $1,535(R)

 $1,535(R)

See next page

Rhode Island

All Applicants

Not Available

Not Available

Not Available

 $

135

 $

135

See next page

South Carolina

All Applicants

$

$

1,889

 $ 1,889

See next page

Utah

Public, State/Federal Agency,
Academic Organization

 $ 830(R)

 $ 830(R)

 $ 830(R)

 $ 830(R)

 $ 830(R)

See next page

Private Organization

 $ 1,630(R)

 $ 1,630(R)

 $ 1,630(R)

 $ 1,630(R)

 $ 1,630(R)

See next page

Not-for-profit Affiliation

 $

 $

 $

 $

 $

655

See next page

For-profit Affiliation

 $ 1,055

 $ 1,255

 $ 1,255

 $ 1,255

 $ 1,255

See next page

All Applicants

 $

 $

 $

 $

 $

See next page

Nebraska

Nevada
New Jersey

35

60

 $

35

60

35

35

35

TOTAL

45H

New York

North Carolina

Vermont
Wisconsin

HCUP SID/SASD/SEDD (11/16/2012)

1,889

555

735

$

1,889

655

835

16

$

1,889

655

835

655

835

835

Uniform State Application

State

HCUP SEDD Price Structure

2009

2010

2011

Students

 $

35

 $

35

 $

35

Non-profit/Educational

 $

135

 $

135

 $

135

For-profit Affiliation

 $

335

 $

335

 $

335

Government, Non-profit Research or
Educational Institution

 $ 35(R)

 $ 35(R)

 $ 35(R)

All Others

 $235(R)

 $235(R)

 $235(R)

All Applicants

 $135(R)

 $135(R)

Not Available

Not-for-profit Affiliation

 $835(R)

 $835(R)

Not Available

For-profit Affiliation

 $1,235(R)

 $1,235(R)

Not Available

Not-for-profit Affiliation

 $

 $585(R)

Not Available

For-profit Affiliation

 $ 1,135

 $1,135(R)

Not Available

All Applicants

 $ 1,535

 $ 1,535

Not Available

Non-profit/Educational

 $ 1,135

Not Available

Not Available

Commercial

 $ 2,635

Not Available

Not Available

Maryland

All Applicants

 $

 $

 $

Massachusetts

All Applicants

 $

All Others
AHRQ Grantee
(Complete Section IV, page 46H18)

Arizona

California
Florida
Hawaii

Iowa
Kentucky
Maine

585

35

 $

35

835

Not Available

 $1,035(R)

 $1,035(R)

Not Available

 $535(R)

 $535(R)

Not Available

Not-for-profit Affiliation

Not Available

 $

435

Not Available

For-profit Affiliation

Not Available

 $

835

Not Available

All Applicants

 $

60

 $

60

Not Available

AHRQ Grantee(Complete Section IV, page 18)

$

535

$

535

Not Available

Non-profit Research

$

535

$

535

Not Available

Students

$

285

$

285

Not Available

All Others

$

1,035

$

1,035

Not Available

Not-for-profit Affiliation

 $ 535(R)

 $ 535(R)

Not Available

For-profit Affiliation

 $1,535(R)

 $1,535(R)

Not Available

Rhode Island

All Applicants

 $ 135

 $ 135

Not Available

South Carolina

All Applicants

 $ 2,335

 $ 2,335

 $ 2,335

Utah

Public, State/Federal Agency, Academic
Organization

 $ 1,630(R)

Not Available

Not Available

Private Organization

 $ 3,205(R)

Not Available

Not Available

Not-for-profit Affiliation

 $ 685

 $ 685

Not Available

For-profit Affiliation

 $ 1,335

 $ 1,335

Not Available

All Applicants

 $

 $

 $

Nebraska

Nevada
New Jersey

45H

New York

North Carolina

Vermont
Wisconsin

835

35

835

835

TOTAL

835

TOTAL DATA COST: Calculate total cost for all data requested.
See Part IV (page 19) for instructions on determining the total payment due:
43H

HCUP SID/SASD/SEDD (11/16/2012)

17

Uniform State Application

Section IV. AHRQ Grantee
Some states offer a discounted price for AHRQ Grant Recipients. If you are an AHRQ Grantee and intend to use
the data requested for a currently funded AHRQ project, you are entitled to the discounted price and should mark
your data request accordingly. Include the name of the principal investigator, title, and the corresponding grant
number in the space provided below. Other types of grants are non-applicable. The Uniform State Application in
no way constitutes a grant application.
The Research Grant Application Form PHS 398 is to be used in applying for AHRQ grants. This form is available
online from the National Institutes of Health Web site at the following URL:
http://www.nih.gov/grants/funding/phs398/phs398.html
18H

Copies of the PHS 398 Grant Application Form are also available from:
AHRQ Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907-8547
Telephone: (800) 358-9295

If you are requesting data at the AHRQ Grantee discounted price, please provide the following information:
Name of Principal Investigator / Title:

AHRQ Grant Number:

HCUP SID/SASD/SEDD (11/16/2012)

18

Uniform State Application

Part IV: Determine the Total Payment Due and Select Payment Method
6B

Total Payment Due
If you need help determining the payment due, submit the completed application (pages 2-35), 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
Total SID Data Cost From Section I:

$_____________

Total SASD Data Cost From Section II:

$_____________

Total SEDD Data Cost From Section III:

$_____________

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.

HCUP SID/SASD/SEDD (11/16/2012)

19

Uniform State 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: _________________________________________________
Requestor’s Phone Number And Extension: _________________________________________________
Project Code Number: ____________________________________________________________________
Date Processed: __________________________

Invoice Numbers Paid: ________________________

Project Code: ______________________________
Input By: __________________________________

HCUP SID/SASD/SEDD (11/16/2012)

20

Uniform State Application

Part V: Indemnification Clause
7B

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 SID, SASD, or SEDD 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 SID, SASD, or SEDD data or the Recipient’s use of the SID, SASD, or SEDD 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 SID, SASD, or SEDD 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 SID, SASD, or SEDD data was used to determine whether the Recipient’s
request to use SID, SASD, or SEDD 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 SID, SASD, or SEDD data provided by SSS. Further, Recipient agrees that SSS
shall not be liable to Recipient for any reason whatsoever arising out of the SID, SASD, or SEDD data or the
Recipient’s use of the SID, SASD, or SEDD data.
Recipient certifies and warrants that it has made no representations to SSS concerning any uses it (Recipient) intends
to make of the SID, SASD, or SEDD 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 SID, SASD, or SEDD data was used to
determine whether the Recipient’s request to use SID, SASD, or SEDD data would be approved.

Signed:

SID/SASD/SEDD Indemnification Clause

Date:

21

Revised 10/19/2012

Part VI: HCUP Data Use Agreement Training
8B

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.
19H

HCUP DUA Training Course Certification Code _______________________________________

HCUP SID/SASD/SEDD (11/16/2012)

22

Uniform State Application

DATA USE AGREEMENT for the
State Inpatient Databases 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 State Inpatient Databases (SID) 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 SID may be granted.
In accordance with HIPAA, the SID 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.

SID Data Use Agreement

23

Revised 11-7-11

The undersigned gives the following assurances with respect to the SID 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 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 provide an abstract and reference for any published research material resulting from the use of
these HCUP State Inpatient Databases to the HCUP Central Distributor.

SID Data Use Agreement

24

Revised 11-7-11



I will acknowledge in all reports based on these data that the source of the data is the specific state(s)
or data organization(s) that submitted data to the HCUP (e.g., “state name(s), State Inpatient
Databases (SID), 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).

SID Data Use Agreement

25

Revised 11-7-11

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: HCUPDistributor@AHRQ.gov
20H

SID Data Use Agreement

26

Revised 11-7-11

DATA USE AGREEMENT for the
State Ambulatory Surgery Databases 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 State Ambulatory Surgery Databases (SASD) 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 SASD may be granted.
In accordance with HIPAA, the SASD 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.

SASD Data Use Agreement

27

Revised 11-7-11

The undersigned gives the following assurances with respect to the SASD 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 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 provide an abstract and reference for any published research material resulting from the use of
these HCUP State Ambulatory Surgery Databases to the HCUP Central Distributor.

SASD Data Use Agreement

28

Revised 11-7-11



I will acknowledge in all reports based on these data that the source of the data is the specific state(s)
or data organization(s) that submitted data to the HCUP (e.g., “state name(s), State Ambulatory
Surgery Databases (SASD), 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).

SASD Data Use Agreement

29

Revised 11-7-11

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: HCUPDistributor@AHRQ.gov
21H

SASD Data Use Agreement

30

Revised 11-7-11

DATA USE AGREEMENT for the
State Emergency Department Databases 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 State Emergency Department Databases (SEDD) 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 SEDD may be granted.
In accordance with HIPAA, the SEDD 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.

SEDD Data Use Agreement

31

Revised 11-7-11

The undersigned gives the following assurances with respect to the SEDD 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 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 provide an abstract and reference for any published research material resulting from the use of
these HCUP State Emergency Department Databases to the HCUP Central Distributor.

SEDD Data Use Agreement

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Revised 11-7-11



I will acknowledge in all reports based on these data that the source of the data is the specific state(s)
or data organization(s) that submitted data to the HCUP (e.g., “state name(s), State Emergency
Department Databases (SEDD), 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).

SEDD Data Use Agreement

33

Revised 11-7-11

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: HCUPDistributor@AHRQ.gov
2H

SEDD Data Use Agreement

34

Revised 11-7-11

Final Checklist:
1B

 Have you completed Part I through Part III of the application (pages 2-14)?
48H

 Have you supplied the necessary information to get the discounted price from some states for AHRQ
Grantees (page 18)?
49H

 Have you determined the total payment due (page 19)?
50H



If paying by check, have you enclosed a check payable to Social & Scientific Systems, Inc. for the
full amount due (page 19)?
51H



If paying by credit card, have you completed and signed the credit card payment form (page 20)?



Have you read and signed the Indemnification Clause (page 21)?



Have you completed the online HCUP Data Use Agreement Training Course and provided your
Certification Code (page 22)?

52H

53H

54H

 If purchasing the SID, have you read and signed the “Data Use Agreement for HCUP State Inpatient
Databases” (pages 23-26)?
5H

56H

 If purchasing the SASD, have you read and signed the “Data Use Agreement for HCUP State
Ambulatory Surgery Databases” (pages 27-30)?
57H

58H

 If purchasing the SEDD, have you read and signed the “Data Use Agreement for HCUP State
Emergency Department Databases” (pages 31-34)?
59H

60H

 Submit your application (pages 2-35) by fax or mail to the HCUP Central Distributor, SSS, Inc.
Contact information is listed on page 1.
61H

62H

63H

For Internal Use Only:
Date Received:____________

DUA Signed/Dated:____________

Order Number:____________

Application Complete:____________ Payment Received:____________

HCUP SID/SASD/SEDD (11/16/2012)

35

Date Shipped: ____________

Uniform State Application