MCD Sponsorship Request Form Guidance

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MCD Sponsorship Request Toolkit
Guidance: Medicaid Confidential Data (MCD) Sponsorship Request Form
Introduction	The law requires that the Department must first consider whether the purpose of each MCD access request administers the Medicaid program. Section 2, below, asks you to describe why your organization is requesting access to MCD, and the purpose for which it will be used. Prepare your answer carefully. Completing the MCD Sponsorship Request Form does not mean that the request will be sponsored. Guidance is provided for informational purposes only and is not legal advice.
What is the MCD Sponsorship Request Form and when do I use it?	The MCD Sponsorship Request Form is intended to help data requestors outside the New York State Department of Health (NYSDOH) Office of Health Insurance Programs (OHIP) who would like to request access to MCD. OHIP contractors and vendors should contact their OHIP contract managers to request MCD OHIP Programs should contact their OHIP Program Managers to request MCD Using the MCD Sponsorship Request Form, the data requestor will provide information about the data request that will be used to determine How the request administers the NYS Medicaid Program Whether the request is for research, public health surveillance, or health care operations
How to fill out the MCD Sponsorship Request Form	This section describes each element of the MCD Sponsorship Form that the requestor will complete.
Section 1. Requestor Information	Requestor Name	First and last name of individual MCD requestor
	Title	Title of the MCD requestor
	Entity	Legal name of the organization or entity requesting the MCD
	Organization Address-Street	Physical street address of the MCD requestor
	Organization Address-City, State and Zip	Physical city, state, and zip code of the MCD requestor
	Telephone	Requestor´s business telephone number
	Email address	Requestor´s valid business email address
	Date of Request	Date the MCD Sponsorship Request Form is submitted by the requestor
Section 2. Please describe, as specifically as possible, why your organization is requesting access to MCD, and how the data will be utilized.	The requestor should provide details about: Why you are requesting access to MCD? How the MCD requestor will support the administration of the NYS Medicaid Program? The expected outcomes of MCD request Will the request create generalizable knowledge? Support the development of a publication or white paper? Improve the health and well-being of Medicaid participants? Support a specific OHIP initiative or program?
Section 3. Data Requested	Check which types of data (Aggregate, PHI, and/or PII) that you are requesting: Aggregate data is data that cannot reasonably be used to identify a specific individual. May include summary data. Personally Identifiable Information (PII) is information that directly identifies an individual (e.g., name, address, social security number or other identifying number or code, telephone number, email address, etc.) or by which an agency intends to identify specific individuals in conjunction with other data elements. Protected Health Information (PHI) is "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The HIPAA Privacy Rule calls this information "protected health information (PHI)." Which specific MCD are you requesting? Provide a description of the data elements you are requesting, along with the fields or specific data elements if known. Specify the time period for which the MCD is requested. This should be a specific date or range, e.g. 2011 or 2013 – 2016
Section 4. If the use of the data is for a specific state program, please specify which state program	Indicate whether the MCD will be used for a NYS state program. The requestor should identify the NYS Program and agency for which you are requesting the data. For example, "I am requesting this data on behalf of the Assertive Community Treatment program at the Department of Community Affairs"
Section 5. Contracts	MCD requestors shall provide information about state, or federal contracts associated with the request. MCD requestors shall indicate whether there is an existing contract between the MCD requestor and DOH, another state entity, or a federal/NYS grant to perform the work for which you are requesting Sponsorship. If yes, provide information about the state entity, the contact information for that entity, the contract/grant number, any other supporting documentation MCD requestors should also provide a copy of the documentation when submitting the MCD Sponsorship request form.
Section 6. How many individuals will be access/using/processing/working with the data?	Provide the number of individuals that you believe will access/use/process/work with the data. The MCD requestor should provide an estimate of the number of people who would access or use MCD as part of the MCD request.
Section 7. Research	To support compliance with federal and state laws, MCD requestors shall provide information about the role of their Institutional Review Board in reviewing their project request. MCD requestors should answer the following questions: Does your entity have an Institutional Review Board (IRB)? Has your institution´s IRB reviewed your proposal? If your IRB has reviewed your proposal, provide IRB documentation with the MCD Sponsorship request form. If your IRB has NOT reviewed, or will not review, your proposal, explain why.
Section 8. Publication	The requestor should provide information regarding the use of the requested data in a publication. The requestor should include the type of publication as well as where, when, and the subject matter of the publication.
Questions? Contact us!	doh.sm.medicaid.data.exchange@health.ny.gov