Fillable Public Use Data File Hospital Inpatient Discharge Data (Texas Secretary of State)

Fill Online, Printable, Fillable, Blank Public Use Data File Hospital Inpatient Discharge Data (Texas Secretary of State) Form

Use Fill to complete blank online TEXAS SECRETARY OF STATE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Public Use Data File Hospital Inpatient Discharge Data (Texas Secretary of State)

On average this form takes 31 minutes to complete

The Public Use Data File Hospital Inpatient Discharge Data (Texas Secretary of State) form is 4 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 121 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Texas Secretary of State forms online.

BROWSE TEXAS SECRETARY OF STATE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Hospital Inpatient Discharge Data, 20201216 Phone: 512-776-7261 | E-mail: thcichelp@dshs.texas.gov
1 of 4
ZZ 700/008
Public Use Data File
Hospital Inpatient Discharge Data Form
Payment accepted by check only
Please complete packet and mail to the address below.
Cost
Type of Business
2018 - **2020
purchased per
calendar year
2018 - **2020
purchased per
calendar quarter
2015 - 2017 per
purchased per
calendar quarter
Texas State Agencies and State
Universities
$0
$0
$0
Texas City/County/Local Government
Health Departments
$0
$0
$0
Texas Reporting Hospitals*
$3,000
$875
$312.50
Texas In-State Media
$3,000
$875
$312.50
Out of State Health Departments
$3,000
$875
$312.50
Texas Private universities/colleges
$6,000
$1,750
$625
Out of State Media
$6,000
$1,750
$625
Out of State Agencies
$6,000
$1,750
$625
Out of State Universities
$6,000
$1,750
$625
Out of State Hospitals
$6,000
$1,750
$625
All other businesses or consumers,
including hospital or ASC affiliates,
organizations, institutions, corporate
offices
$6,000
$1,750
$625
Multiple Organizational Discounts
See page 4
No Discount
2006-2014
Free download:
http://www.dshs.texas.gov/THCIC/Hospitals/Download.shtm
ORDER
Data Year
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Cost
Total:
Send completed Form, Data Use Agreement and CHECK
PAYABLE TO:
Texas Health Care Information Collection ZZ 700/008
Send Documents and Check to:
Cash Receipts Branch, MC 2003
Texas Department of State Health Services
PO Box 149347
Austin, TX 78714-9347
**2020 Data Release Timeline
1q20-Dec 2020
2q20-Mar 2021
3q20-Jun 2021
4q20-Sep 2021
Hospital Inpatient Discharge Data, 20201216 Phone: 512-776-7261 | E-mail: thcichelp@dshs.texas.gov
2 of 4
ZZ 700/008
Data Use Agreement
Hospital Inpatient Discharge Public Use Data File
Sections 108.013(c)(1) and (2) and 108.013 (g) of the Texas Health and Safety Code (THSC) prohibit the Texas
Department of State Health Services (DSHS) from releasing, and a person or entity from gaining access to, any data
that could reveal the identity of a patient or the identity of a physician unless specially authorized under Chapter 108
of THSC.
Any effort to determine the identity of any person or to use the information for any purpose other than for analysis
and aggregate statistical reporting violates the THSC and this data use agreement. By virtue of this agreement, the
undersigned agrees that the data will not be used to identify an individual patient or physician.
Any questions about the data must be referred to the DSHS manager in charge of implementing Chapter 108 of THSC.
Product support is not provided by DSHS.
The data are protected by United States copyright laws and international treaty provisions.
In this data use agreement, the requestor of the data is referred to as the “licensee, ” and can be any organization,
employee of an organization, consumer or data purchaser that is responsible for complying with the following
requirements:
By initialing each item, the licensee gives the following assurances with respect to the use of Texas Inpatient
Discharge Data sets:
The licensee acknowledges the data is limited to the organization’s physical location (specified below)
unless purchasing a multiple organizational license;
The licensee will not release nor permit others to release the individual patient records or any part of
them to any person who is not a staff member of the organization (specified below), except with the written
approval of DSHS;
The licensee will not attempt to link nor permit others to attempt to link the inpatient records of patients
in this data set with personally identifiable records from any other source;
The licensee will not release nor permit others to release any information that identifies persons, directly
or indirectly;
The licensee will not attempt to use nor permit others to use the data to learn the identity of any
physician;
The licensee will not nor permit others to copy, sell, rent, license, lease, loan, or otherwise grant access to
the data covered by this Agreement to any other person or entity, unless approved in writing by DSHS;
The licensee acknowledges that when releasing or disclosing the data set or any part to others in their
organization they will retain full responsibility for the privacy and security of the data and will prohibit others
from further release or disclosure of the data;
The licensee agrees to read the User Manual and understand the limitations of the data (User Manual
located at: www.dshs.texas.gov/thcic);
The licensee will periodically check the DSHS/CHS/THCIC website for any technical updates to the data
(www.dshs.texas.gov/thcic);
The licensee will use the following citation in any publication of information from this file as: Texas
Hospital Inpatient Discharge Public Use Data File, [quarter and year of data]. Texas Department of State
Health Services, Austin, Texas. [date of publication];
The licensee will indemnify, defend and hold the DSHS, its members, employees, and its contract vendors
harmless from any and all claims and losses accruing to any person as a result of violation of this agreement;
and
The licensee will make no statement nor permit others to make statements indicating or suggesting that
interpretations drawn from these data are those of DSHS.
Hospital Inpatient Discharge Data, 20201216 Phone: 512-776-7261 | E-mail: thcichelp@dshs.texas.gov
3 of 4
ZZ 700/008
For the purposes of this data use agreement an “Organization” is defined by its physical location (street address).
Organizations that have multiple physical locations shall restrict access of the requested files listed on this document
to the location listed on the document, unless purchasing a multiple organization license. (See page 4)
Note: Organization staff at the location listed on this document or contracted business associates to the licensee listed
that do not regularly work at the physical location listed on this document are required to obtain their own data
through DSHS, except with the written approval of DSHS.
Sharing of the data between two organizations, regardless of affiliation, is only allowed with the written approval of
DSHS.
The licensee is required to comply with all federal and state confidentiality laws. The licensee agrees to the foregoing
restrictions and acknowledges that the knowing or negligent release of data in violation of Chapter 108, Health and
Safety Code, is punishable by a civil penalty of up to $10,000 under section 108.014 and is a state jail felony under
section 108.0141 and any other remedies available under the law to DSHS.
Please indicate the organization business type; mark only one type:
X
Business Type
X
Business Type
Texas State Agencies and State Universities
Out of State Media
Texas City/County/Local Government Health
Departments
Out of State Agencies
Texas Reporting Hospitals (provide THCIC ID
below)
Out of State Universities
Texas In-State Media
Out of State Hospitals
Out of State Health Departments
All other businesses or consumers, including
hospital or ASC affiliates, organizations,
institutions, corporate offices
Texas Private universities/colleges
Signature of Licensee: _________________________________________ Date: _________________
Print or Type Name of Licensee: ________________________________________________________
Title (if part of an Organization): _________________________________________________________
Organization: _______________________________________ *THCIC ID (for reporting hospitals only) _________
Organization Physical Address: _________________________________________________________
Mailing Address (if different than above): __________________________________________________
City: ________________________________________ State: _________ ZIP: ___________________
Phone Number: _____________________________________________________________________
Fax Number: _______________________________________________________________________
E-mail: ____________________________________________________________________________
Note to Licensee: Data product will be shipped to the mailing address provided above.
click to sign
signature
click to edit
Hospital Inpatient Discharge Data, 20201216 Phone: 512-776-7261 | E-mail: thcichelp@dshs.texas.gov
4 of 4
ZZ 700/008
Pricing for multiple organization license (Organizations that own one or more health care facilities that are required
to provide data under Health and Safety Code, Chapter 108 the price will be 50% of the prices listed below.) Licensee
is responsible for providing PUDF copies to the multiple located licensees.
2 – 4 license locations; 2018 – 2020 data year = $9,000 per data year
2 – 4 license locations; 2015 - 2017 data year = $3,750 per data year
5 - 9 license locations; 2018 – 2020 data year = $12,000 per data year
5 - 9 license locations; 2015 - 2017 data year = $5,000 per data year
10+ license locations; 2018 – 2020 data year = $15,000 per data year
10+ license locations; 2015 - 2017 data year = $6,250 per data year
Type the names and physical addresses of each affiliated organization your organization will be licensing.
Location #1 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
Location #2 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
Location #3 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
Location #4 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
Location #5 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
Location #6 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
Location #7 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
Location #8 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
Location #9 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
Location #10 Name:
THCIC ID (if applicable):
Street:
City:
State:
ZIP Code:
If additional locations, copy this page and renumber the location sites.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Public Use Data File Hospital Inpatient Discharge Data (Texas Secretary of State)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document