Form Cms-R-0235m - Medicaid Agency Data Use Agreement Page 2

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
INSTRUCTIONS FOR COMPLETING THE DATA USE AGREEMENT (DUA)
Additional Custodian individuals or organizations can be included as necessary over the life of the primary
DUA. To include a new Custodian under an existing Medicaid agency DUA, submit the following to the
CMS Regional Office: a letter from the Medicaid agency describing the activities planned for the new
Custodian and the length of time over which the Custodian will serve; and a Multi-Signature Addendum
completed and signed by an appropriate lead or managerial person from the Custodian organization. The
Multi-Signature Addendum must show the DUA number of the existing primary Medicaid agency DUA.
• Item #16 will be completed by the RO MDS Representative.
• Item #17 will be completed by the CMS Regional and Central Office.
Form CMS-R-0235M (07/07) EF 07/2007
2

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