Hipaa Compliance Data Use Agreement Form

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FOR INTERNAL USE ONLY
HIPAA COMPLIANCE DATA USE AGREEMENT
This Data Use Agreement (“Agreement”) is made and entered into as of this ________________
day of ____________, 20__ by and between the University of North Texas Health Science
Center(“Covered Entity”), and _____________________________ (“Data Recipient”).
1. This Agreement sets forth the terms and conditions pursuant to which Covered Entity will Disclose
certain Protected Health Information (PHI) to the Data Recipient.
2. Except as otherwise specified herein, Data Recipient may make all Uses and Disclosures of the
Limited Data Set necessary to conduct the research described herein: ________________
__________________________________________________________(“Research Project”)
Include a br ief descr iption of the r esear ch and/or IRB pr otocol number .
3. In addition to the Data Recipient, the individuals, or classes of individuals, who are permitted to Use
or receive the Limited Data Set for purposes of the Research Project, include:
___________________________________________________________________________
___________________________________________________________________________
4. Data Recipient agrees to not Use or Disclose the Limited Data Set for any purpose other than the
Research Project or as Required by Law.
5. Data Recipient agrees to use appropriate safeguards to prevent Use or Disclosure of the Limited
Data Set other than as provided for by this Agreement.
6. Data Recipient agrees to report to the Covered Entity any Use or Disclosure of the Limited Data Set
not provided for by this Agreement, of which it becomes aware, including without limitation, any
Disclosure of PHI to an unauthorized subcontractor, within ten (10) days of its discovery.
7. Data Recipient agrees to ensure that any agent, including a subcontractor, to whom it provides the
Limited Data Set, agrees to the same restrictions and conditions that apply through this Agreement
to the Data Recipient with respect to such information.
8. Data Recipient agrees not to identify the information contained in the Limited Data Set or contact
the individual.
UNTHSC
DATA RECIPIENT
________________________________
________________________________
Name: ___________________________
Name: ___________________________
Title: ____________________________
Title: ____________________________
Data use agreement.internal recipient.
1

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