Form Cms-R-0235a - Data Use Agreement (Dua) Addendum For Data Acquired From The Centers For Medicare & Medicaid Services (Cms) 2012

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

OMB No. 0938-0734

CENTERS FOR MEDICARE & MEDICAID SERVICES

DATA USE AGREEMENT (DUA) ADDENDUM for Data Acquired from the

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

The following individual(s) requests access to CMS data. Their signature(s) attest to their agreement with the

terms and conditions defined in the original documentation for Data Use Agreement (DUA) ___________ or

for new DUA study/project name ______________________________________________________________

Part A

_______ Requester _______ Custodian _______ Subcontractor _______ Recipient

Printed Name ___________________________________ Phone ____________________ Ext______________

Organization _______________________________________________________________________________

Street Address _____________________________________________________________________________

City _________________________________State _____________Zip ________________________________

E-mail _______________________________

Signature

(if applicable) Courier name _______________________ Account number _____________________________

Part B

_______ Requester _______ Custodian _______ Subcontractor _______ Recipient

Printed Name ___________________________________ Phone ____________________ Ext______________

Organization _______________________________________________________________________________

Street Address _____________________________________________________________________________

City _________________________________State _____________Zip ________________________________

E-mail _______________________________ Signature

(if applicable) Courier name _______________________ Account number _____________________________

Contracting Officer Representative (COR)/Government Task Lead (GTL) or CMS Privacy Staff

Printed Name ______________________________

Signature ______________________________________

Organization_______________________________

Please send as an email attachment to DataUseAgreement@cms.hhs.gov, and see our website at

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB

control number for this information collection is 0938-0734. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to

review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the

time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Md. 21244-1850.

Form CMS-R-0235A (06/12)