HEALTH ECONOMICS PROGRAM
MN APCD Public Use File: Request Form
Name (print): _________________________________________
Organization: _________________________________________
Email (to receive PUF): _________________________________________
Phone: _________________________________________
How would you best describe yourself or your organization?
Agency/regulator
Health care provider
Health care payer
Employer
Researcher
Consumer/patient
Other: _________________________________________
I would like to receive the following files:
Health care services 2013
Primary diagnoses 2013
Health care use 2013
The Minnesota Department of Health (MDH) is pleased to provide the Minnesota All Payer Claims Database (MN APCD)
Public Use Files (PUF)s, listed in this document, to the public at no cost. These PUFs are intended to provide summarized
information on Minnesota’s population health care claims data research.
To maintain compliance, all shared MN APCD Public Use File(s) must include the entire zip file, including all disclaimers.
LICENSE FOR USE OF UB-04 REVENUE CODES, COPYRIGHT © 2013
Copyright © 2013, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the
AHA copyrighted materials contained within this publication may be copied without the express written consent of the
AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized
within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity
wishes to utilize any AHA materials, please contact the AHA at 312-893-6816.
Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal
purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04
Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof,
including the codes and/or descriptions, is only authorized with an express license from the American Hospital
Association.”
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HEALTH ECONOMICS PROGRAM
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)
CPT only copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American
Medical Association.
You, your employees and agents are authorized to use CPT only as contained in MN APCD Public Use Files (PUFs) solely for
your own personal use in directly participating in healthcare programs administered by Company. You acknowledge that
the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of
CPT for resale and/or license, transferring copies of CPT to any party not bound by this Agreement, creating any modified
or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must
be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash
Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site,
www.ama-assn.org/go/cpt.
U.S. Government Rights
This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the
American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does
not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and
DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association
reserves all rights to approve any license with any Federal agency.
Disclaimer of Warranties and Liabilities.
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied
warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors
and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use.
The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content
of this product is with Company, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility
for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained
or not contained in this product.
This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
In accepting the PUFs, I acknowledge the following:
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Before submitting this request, I read the documentation about the PUFs posted on the MDH website.
I accept the data files as presented, understanding that the source files and the PUFs are accurate
representations of the information that data submitters provide to the MN APCD.
I understand that I am solely responsible for any data manipulations, analysis, displays and interpretation of the
data.
I acknowledge that I have read and understand the terms and conditions of the license for use of Current
Procedural Terminology, fourth edition (“CPT®”) and UB-04 Revenue Codes, copyright © 2013.
(check box) Yes, I understand this Disclaimer.
Please return this completed form via email or postal mail to the Minnesota Department of Health:
Email: [email protected]
Mailing address:
Minnesota Department of Health, Health Economics Program
85 E. 7th Place, Suite 220
St. Paul, MN 55101
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