MCD Sponsorship Request Toolkit

• Guidance is also available in Portable Document Format (PDF)

Guidance: MCD Sponsorship Closeout
How do I closeout my MCD Sponsorship?	Upon expiration of DUA/DEAA, Requestor submits the Data Destruction Affidavit form to Security and Privacy Bureau Security and Privacy Bureau provides DUA/DEAA Closure Letter
Do I need to use a specific form or template?	Yes, the Data Destruction Affidavit form needs to be completed
How do I obtain the Data Destruction Affidavit form?	There are two ways to obtain the Data Destruction Affidavit form: It is Attachment B to the DUA Request one from the Security and Privacy Bureau
How do I complete the Data Destruction Affidavit?	Section 1: Fill out name Section 2: Fill out your organization and organization´s address Section 3: Enter what type of MCD received from NYSDOH, DUA Identification number, and the purpose of the DUA Section 4: No action needed Section 5: Check if MCD was returned to NYSDOH or destroyed and date of such Section 6: If data was destroyed, enter the name of the entity that destroyed Section 7: No action needed Section 8: Individual who performed the destruction or the Requestor on the DUA needs to sign, date, and have the affidavit notarized
Questions? Contact us!	doh.sm.medicaid.data.exchange@health.ny.gov