Hipaa De-Id Certification Form

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Principal Investigator:
Research that involves the use of “de-identified” Protected Health Information (PHI) is exempt
from HIPAA requirements. This application should be used when a researcher requests de-
identified data for use in research, or when a researcher who is a hospital employee wishes to
create de-identified data to be used or disclosed for a research project.
The following identifiers must be removed from the data set to create de-identified
Names (individual, employer, relatives, etc.)
Address (street, city, county, precinct, zip code – initial 3 digits if geographic unit
contains less than 20,000 people, or any other geographical codes)
Telephone and Fax numbers
Social Security numbers
Dates (except for years)
Birth date
Admission date
Discharge date
Date of death
Ages >89 and all elements of dates indicative of such age (except that
such age and elements may be aggregated into a category “Age >90”)
E-mail addresses
Health Plan Beneficiary numbers
Account numbers
Certificate/license numbers
Vehicle Identifiers and Serial numbers (e.g., VINs, License Plate numbers)
Device Identifiers and Serial Numbers
Web Universal Resource Locators (URLs)
Internet Protocol (IP) address numbers
Biometric Identifiers (e.g. finger or voice prints)
Full face photographic images) and any comparable images
Any other unique identifying number, characteristic, or code
Please indicate the source of the de-identified data:
Please list below the information requested in the de-identified data set:


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