CMS-R-235 LDS DUA Request Application

ATTACHMENT A: LIMITED DATA SET (LDS) REQUEST APPLICATION

	DUA Requester
	Individual authorized to sign agreements on behalf of the requesting organization.
	Requesting Organization
	Organization with which the LDS DUA is established.
	Study Title
	Title of the research study or project.
EXECUTIVE SUMMARY

1. Study Description

Please describe your study background, objectives, aims, and purpose.

To be approved under current Centers for Medicare & Medicaid Services (CMS) policy, the purpose of your study must be designed in a way that is expected to demonstrate the potential to improve the quality of life for Medicare beneficiaries, Medicaid recipients, and/or Health Insurance Exchange consumers or improve the administration of the Medicare or Medicaid programs or Health Insurance Exchanges, including payment-related projects.

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2. Other than the CMS LDS files you are requesting, please list any additional data files or sources of information that you are planning to use to support your research study (e.g., Provider of Services (POS) file, American Medical Association (AMA)

Physician Master file, etc.)

Name of additional files	Purpose for using the data file in the analysis

PUBLIC DISSEMINATION OF FINDINGS

3. Describe your plans for publicly disseminating the findings from your analysis, including specific media through which you will report results.

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4. Please tell us about any products or tools you will be creating to sell, in addition to the findings that will be made publicly available. If you will not be creating additional products or tools, please state N/A.

(Provide detailed information on the product or tool and the audience that you will be targeting. The product or tool that will be created must stem from the research described in the above executive summary. Note – this product cannot be used for marketing as defined in 45 C.F.R. § 164.501 or to create the potential for fraud, waste, and/or abuse in CMS programs. Any CMS data provided in the product or tool must meet the de-identification requirements in the LDS DUA sections 4 and 5).)

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ATTACHMENT A: LIMITED DATA SET (LDS) REQUEST APPLICATION

5. Data Management Safeguards

Please provide the name of your DMP SAQ approved through the Data Privacy Safeguards Program (DPSP):

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