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Potentially Identifiable Information means information that includes indirect identifiers which <br />may permit linking an individual to that person's health care information. Examples of <br />potentially identifiable information include: <br />• birth dates, <br />• admission, treatment or diagnosis dates, <br />■ healthcare facility codes <br />• other data elements that may identify an individual. These vary depending on factors <br />such as the geographical location and the rarity of a person's health condition, age or <br />other characteristic. <br />Restricted Confidential Information means confidential information where especially strict <br />handling requirements are dictated by statutes, rules, regulations or contractual agreements. <br />Violations may result in enhanced legal sanctions. <br />State Holidays - Days of the week excluding weekends and state holidays; namely, New <br />Year's Day, Martin Luther King Jr. Day, President's Day, Memorial Day, Labor Day, <br />Independence Day, Veterans' Day, Thanksgiving day, the day after Thanksgiving day, and <br />Christmas. Note: When January 1, July 4, November 11 or December 25 falls on Saturday, the <br />preceding Friday is observed as the legal holiday. If these days fall on Sunday, the following <br />Monday is the observed holiday <br />I. PURPOSE AND AUTHORITY/SCOPE OF AGREEMENT <br />PURPOSE (include a description of how the data will be used and any provisions for re - <br />disclosure) <br />The data will be used for community health assessments that will be updated annually. <br />Parties shall use the information described in this Agreement solely for the purpose stated <br />this Agreement. <br />II. STATUTORY AUTHORITY TO SHARE INFORMATION <br />Are there specific laws or regulations that prohibit release or compromise of this data? <br />® Yes ❑ No <br />If yes, list laws or regulations: <br />DOH statutory authority to disclose the confidential information or limited Dataset(s) <br />identified in this agreement to the Information Recipient: <br />RCW 43.20.050 -Powers and duties of state board of health <br />RCW 43.70.050 - Collection, use, and accessibility of health-related data <br />RCW 70.02.050 - Disclosure without patient's authorization. <br />RCW 43.70.052 - Hospital financial and patient discharge data <br />Information Recipient's statutory authority to receive the confidential information or limited <br />Dataset(s) identified in this Agreement: RCW 70.58.104 (Disclosure of vital Records for research purposes) <br />and WAC 246 -490 -010 -WAC 246-490-030 (Requesting vital records information with personal identifiers (WAC <br />246-490-030) or without personal identifiers WAC 246-490-020). RCW 43.70.052 - Hospital financial and patient <br />discharge data <br />Is the purpose of this agreement for research? <br />❑ Yes ® No <br />Page 3 of 16 <br />rev 07/02/2013 <br />