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  HOME > Health Sevices Research > Request to Obtain Michigan Medicaid Warehouse Data

 

 

Request to Obtain Michigan Medicaid Warehouse Data

Project Title:
Name/Title of Principal Investigator requesting data:
Contact Information
Street:
City:
State:

Phone:
Email:
Fax:
Brief description of activity:
Why is Medicaid data being sought?  What question(s)
will be answered with data results?
Brief description of the data requested:
Participating agencies:
With whom will data be shared?
Will these data be used for reporting or publication?
Yes No
Will IRB approval be sought?
Yes No
(Note: IRB approval will be sought through MSU’s UCRIHS, unless otherwise
noted above, and proof of approval will be shared with MDCH.)

Principal Investigator Attestation:
By submitting this form, I attest that I have reviewed the provisions outlined in the HIPAA Business Associate Addendum (BAA) and Attachment A of the BAA.  I agree to use and maintain Medicaid data according to the provisions and scope outlined in the BAA and Attachment A.