SampleInteragencyDataSharingAgreementSampleInteragencyDataSharingAgreementSampleInteragencyDataSharingAgreement
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Sample Interagency Data-Sharing Agreement
Centers for Medicare and Medicaid Services

State of:
Requester
Agency Name:
Data User:
Title:
Address:
Phone:
Data Provider
Agency Name:
Custodian:
Title:
Address:
Phone:
I. PURPOSE
In this section, both parties must state in non-technical language the purpose(s) for which they are
entering into the agreement, i.e., how the data will be used, what studies will be performed, or what the
desired outcomes are perceived to be as a result of obtaining the data. The source of the data will come
from any and all public health or claims databases. The data will only be used for research and/or
analytical purposes and will not be used to determine eligibility or to make any other determinations
affecting an individual. Furthermore, as the data will be shared within a State, it will be subjected to all
applicable requirements regarding privacy and confidentiality that are described herein.
II. PERIOD OF AGREEMENT
The period of agreement shall extend fro