*All Fields are Required

This request form is to ensure compliance with the following policies:

• Third Party Registry Selection (UNMC 6300; Nebraska Medicine IM43),
• Privacy, Confidentiality and Information Security (UNMC 6045, Nebraska Medicine IM06),
• Computer Use and Electronic Information Security (UNMC 6051, Nebraska Medicine IM01),
• Audit of Electronic Protected Health Information (ePHI) in Information Systems (UNMC Information Security Procedure; Nebraska Medicine SYS021)
• File Transfer of Confidential Information Guidelines (UNMC Information Security Procedure; Nebraska Medicine SYS013).

Requestor Name:

Title/Role:

Email Address: (must be unmc.edu or nebraskamed.com address)

Executive Sponsor Name:

Sponsor Title/Role:

I am requesting submission to by

1. Describe in detail the purposes for which you are requesting the submission of data to a registry for.
   • Incentive bonus - amount and date required to submit to achieve
   • Penalty avoidance - amount and date required to submit to achieve
   • Accreditation - required to obtain/retain accreditation
   • Quality objective - quantifiable benefits due to specified quality goals
   • Research objective - quantifiable benefits due to specified research goals
     
2. Please provide a data dictionary for the data elements that will need to be collected and submitted to the third party.
   
3. Describe how the data elements will be collected as part of a clinical workflow within OneChart.
   
4. Is there a signed legal agreement (BA or contract)? If so please provide copies as part of this request as well as identification of the committees or colleagues that reviewed and approved the agreement. Does the agreement include an indemnification clause?
   
5. Will the entities that are sent and access the data be tracked and audited?
   
6. What is the level of encryption on transferred and stored files?
   
7. How is user authentication handled?
   
8. Does the vendor have restrictions in place on the usage of portable storage methods like USB drives or exports to flat files?
   
9. What cyber liability coverage is provided?
   
10. How is protected health information de-identified? Is it applied to both discrete and non-discrete data?
    
11. If our relationship with the third party ends is there a way to remove previously submitted protected health information?
    
12. If a patient wants to be excluded from the submission, is there a way to remove them both from new submissions as well as from previously submitted information?
    
13. Is there a quality assurance methodology applied to the submitted data to ensure accuracy?
    
14. What resources are required to implement and to maintain the system on an ongoing basis? This should include both clinical and technical resources. If the third party has provided an implementation plan please include as part of this submission.
    
15. Are there any additional costs associated with this submission (in addition to resources)? This should include both hardware and software costs.
    

Agree and Sign

1. I agree to comply with
   • Third Party Registry Selection (UNMC 6300; Nebraska Medicine IM43),
   • Privacy, Confidentiality and Information Security (UNMC 6045, Nebraska Medicine IM06),
   • Computer Use and Electronic Information Security (UNMC 6051, Nebraska Medicine IM01),
   • Audit of Electronic Protected Health Information (ePHI) in Information Systems (UNMC Information Security Procedure; Nebraska Medicine SYS021)
   • File Transfer of Confidential Information Guidelines (UNMC Information Security Procedure; Nebraska Medicine SYS013).
2. I certify that use of the PHI/de-identified data described above will be used only for the purpose stated above.
3. I certify that the requested data is the minimum amount of PHI/de-identified data necessary to accomplish the purposed stated above.
4. I agree to destroy the PHI/de-identified data after use.
5. I agree to store the PHI/de-identified data on secure network servers or encrypted AND password protected local computer drives or mobile devices.

Yes, I acknowledge that I have read and agree with the above

Signed:
Date: 05/14/2024