Get Ab2876 Request Hospitals Hirc-499 - Ca Oshpd - Oshpd Ca

This guide provides detailed instructions on how to effectively complete the AB2876 Request Hospitals HIRC-499 form online. Designed for licensed California hospitals, this form requests access to nonpublic patient-level data in compliance with state regulations.

Follow the steps to complete the AB2876 form accurately.

1. Click ‘Get Form’ button to access the AB2876 Request for Nonpublic Patient Level Data form and open it for completion.
2. Begin by filling out the identification/eligibility section. Provide the name of the hospital CEO or administrator, along with the hospital's name, license number, address, phone number, email address, and indicate if the hospital is a non-profit. If applicable, attach a copy of the 501(c)(3) documentation.
3. Complete the contact information for the designated point of contact for the data request if it differs from the CEO or administrator. Include their name, department, address, phone number, and email.
4. In the purpose section, indicate the reason for the data request, whether for health care operations, research, or other purposes. Provide a detailed description of how the data will be used.
5. List the business units within the hospital that will receive and utilize the requested data. Include the title of the responsible individual in each unit.
6. If the data will be shared externally, indicate the entities or individuals, along with the relevant HIPAA compliance basis for this disclosure.
7. Identify any contractors who will receive data outside of the hospital. Provide the contractor's details, including name, contact information, and a description of how the data will be provided.
8. Specify the types of data requested from OSHPD, including patient discharge data, ambulatory surgery data, or any specific datasets. Indicate the years of data needed.
9. Select the preferred format for the requested data sets. Options include SAS, comma delimited, or custom formats available for specific years.
10. Review and initial each acknowledgment statement confirming the understanding of HIPAA regulations and responsibilities regarding the data. Sign and date the form to finalize your request.
11. Once the form is completed, save any changes made, and choose to download, print, or share the form as needed.

Complete the AB2876 Request Hospitals HIRC-499 form online today to ensure compliance and access to essential patient-level data.