RIF Extension Request_JobAid

Instructions for completing the RIF Data Use Agreement:
Extension Request
This document: All Research Identifiable File (RIF) Data Use Agreements (DUA) are valid for up to one

year. An extension request is required if a study is continuing past the DUA expiration date.
Dissemination of findings into the public domain is a requirement under HIPAA for data disclosure of
research. Information regarding dissemination of findings is required for an extension request.

General Instructions

AF
T

1. Answer every item in the document.
2. Do not alter the layout or content of the document.
3. Submit to ResDAC signed in PDF format.

Specific Instructions

A

RESEARCH IDENTIFIABLE FILE (RIF) DATA USE AGREEMENT: EXTENSION REQUEST

B

GENERAL INSTRUCTIONS

The Health Insurance Portability and Accountability Act (HIPAA) allows data disclosure for research purposes with the
systematic investigation designed to develop or contribute to generalizable knowledge [45 C.F.R. § 164.512(d)]. To request
an extension to a DUA, publication information is required to be provided to CMS.
DUA Requester

A

Requesting Organization

B

Study Title

C

DUA #

D

Must match the individual specified in the RIF DUA.

Must match the organization specified in the RIF DUA.

Must match the study title specified in section 3 of the RIF DUA
CMS assigned DUA number

REQUIREMENTS TO EXTEND DUA

E
Current DUA Expiration Date ______________________

R

Enter the name of the Requester listed
on the RIF Data Use Agreement (DUA).
The Requester is the individual authorized to sign agreements on behalf
of the requesting organization. This
person is often referred to as the ‘legal
signatory’. This person accepts all
terms and conditions in the DUA and
attests that all information contained
in the request is accurate.

D

Enter the exact legal name of the Requesting Organization listed on the RIF
DUA in section 1.

C

1.

F
Requested DUA Expiration Date ___________________

G
Anticipated Study End Date ______________________

2.

H

3.

Are you a participant in the CMS Innovator program?
Please check one.
Yes
No

Provide information on the published findings or plan to publish for research conducted under the DUA. If participating
in the CMS Innovator Program, provide information on any products/tools created in addition to research findings:

I

Enter the exact Study Title listed on
the RIF DUA in section 3.

D

Enter the DUA number of the DUA you
are extending.
(Instructions continue on page 2)
continues on page 2.
Instructions for completing the RIF Data Use Agreement: ExtensionForm
Request
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E

RESEARCH IDENTIFIABLE FILE (RIF) DATA USE AGREEMENT: EXTENSION REQUEST

Enter the current expiration date
listed on the DUA. This date must be
exactly correct. If you are not sure,
see the EPPE Training Module for
instructions to view your DUA.
A request for an extension can be
processed no more than 60 days prior
to the current expiration date.

The Health Insurance Portability and Accountability Act (HIPAA) allows data disclosure for research purposes with the
systematic investigation designed to develop or contribute to generalizable knowledge [45 C.F.R. § 164.512(d)]. To request
an extension to a DUA, publication information is required to be provided to CMS.
DUA Requester

A

Requesting Organization

B

Study Title

C

DUA #

D

Must match the individual specified in the RIF DUA.
Must match the organization specified in the RIF DUA.
Must match the study title specified in section 3 of the RIF DUA
CMS assigned DUA number

REQUIREMENTS TO EXTEND DUA
1.

F

E
Current DUA Expiration Date ______________________

F
Requested DUA Expiration Date ___________________

G
Anticipated Study End Date ______________________
2.

H

Are you a participant in the CMS Innovator program?
Please check one.
Yes
No

AF
T

Enter the requested DUA expiration
date. A DUA can be extended for no
more than one year.

G

GENERAL INSTRUCTIONS

3.

Provide information on the published findings or plan to publish for research conducted under the DUA. If participating
in the CMS Innovator Program, provide information on any products/tools created in addition to research findings:

I

Enter the end date that all anticipated
work on this study will be completed.

H
I

R

If the DUA being extended is part
of the CMS Innovator program, you
must select ‘Yes’. Otherwise, select
‘No’.

Form continues on page 2.

D

For all DUA types, provide information regarding published findings
or plans of disseminating findings
related to the research covered by
this DUA.
If this DUA is part of the CMS
Innovator program, provide information regarding any products or
tools created or plans to create any
products or tools as part of the project covered by this DUA.

Instructions for completing the RIF Data Use Agreement: Extension Request | page 2

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J

RESEARCH IDENTIFIABLE FILE (RIF) DATA USE AGREEMENT: EXTENSION REQUEST

For all DUA types, provide links to
any published findings related to the
research covered by this DUA.
If this DUA is part of the CMS
Innovator program, provide links to
any products or tools created as part
of the project covered by this DUA.

K

Provide links to the published findings that contribute to generalizable knowledge. If participating in the CMS Innovator
Program, also include a link to any product/tool:

J

ATTESTATIONS
1.
2.
3.
4.

We are still using this data as originally requested for our Project/Study.
In accordance with the terms and conditions of the DUA, we understand that the data for this DUA may not be used in any
form, or for any additional work, outside the scope of this DUA without the expressed written consent of CMS.
I have reviewed the contact information on the DUA and submitted necessary updates.
We request a one (1) year [or less, if applicable] extension for the DUA number listed above.

K
Signature

Date

AF
T

The Requester or a Data Custodian
listed on the DUA must sign this form.
The signatory is attesting to the four
attestation statements above. CMS
will accept digital signatures on this
form.

4.

The Requester is the individual authorized to sign agreements on behalf
of the requesting organization. This
person is often referred to as the ‘legal signatory’. This person accepts all
terms and conditions in the DUA and
attests that all information contained
in the request is accurate.

D

R

A Data Custodian is an individual
who will be responsible for ensuring
that the environment in which the
CMS data is stored complies with all
applicable CMS data security requirements, including the establishment
and maintenance of security arrangements to prevent unauthorized use.
For physical data, this is the individual that is listed on the DMP Self-Attestation Questionnaire (SAQ).

Instructions for completing the RIF Data Use Agreement: Extension Request | page 3

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