Medicare Data Release Agreement
(Initial year: _______)
Carrier name ____________________________________ Contract #________
Enrollment Code(s)__________________________________________________
By the signature of the Contracting Official below, the Carrier contracting with the Office
of Personnel Management, hereby agrees
ü to limit access, use and disclosure, and
ü to physically safeguard the records of CSRS and FERS retirees, their spouses, and
survivor annuitants who are enrolled in the Plan named above and who are also
Medicare enrollees,
in accordance with the FEHB/MEDICARE Enrollment Data Exchange Agreement
between the Office of Personnel Management and the Social Security Administration, as
follows:
Data Exchange Agreement
Ø "OPM and SSA agree that the data obtained from SSA will be used only for
the administration of the Federal Employees Health Benefits Program (Chapter
89, title 5, United States Code) and in coordinating benefits through the
individual health benefits carriers who contract with OPM;
Ø to restrict access to the records created by the exchange to authorized personnel
whose duties and responsibilities require access;
Ø that the records involved in the exchange and the data contained therein will be
provided adequate security;
Ø that the files exchanged will not be duplicated or disseminated within or
outside OPM or SSA without written authority except as allowed by
regulations which permit disclosures among Federal or federally assisted
programs;
Ø files provided by OPM will remain the property of OPM, and files provided by
SSA will remain the property of SSA;
Ø access to the data will be restricted to only those authorized employees and officials
who need it to perform their official duties in connection with the intended use of the
data;
Ø the data will be processed under the immediate supervision and control of authorized
personnel in a manner which will protect the confidentiality of the data in such a way
that unauthorized persons cannot retrieve the data by means of a computer, remote
terminal or other means;
Ø personnel who will have access to the data will be advised of the confidential nature
of the information and the civil sanctions for noncompliance contained in the
applicable Federal Statutes;
Ø the data will be stored in an area that is physically safe from access by unauthorized
persons during duty hours as well as non-duty hours or when not in use; and
Ø to reserve the right to make on-site inspections or to make other provisions to ensure
that adequate safeguards are being maintained."
Further, Carrier acknowledges that the Medicare match information was obtained under
assurances by OPM that all actions would be applied prospectively; therefore, the Carrier agrees
that no action will be taken to collect overpaid benefit payments from subscribers based solely
on information supplied by this match.
Authorized Contracting Official:
Signature ____________________________________ Date ______________
Name & Title _____________________________________________________
Carrier: _______________________Enrollment Code(s)___________________
Phone__________________ FAX__________________ Email______________
Address: