If you are seeking support to extract and/or analyze patient data governed through the Consortium Memorandum of Understanding (MOU), please complete this electronic form. You may submit only one request per form.

You may be asked to verify data confidentiality or PHI training within the past year, as directed by this application.

If you do not have authority to sign this application, you will need a supervisor to sign before submitting this application.

Thank you very much.

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