Form Cms-R-0235m - Medicaid Agency Data Use Agreement Page 3

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0734
MEDICAID AGENCY DATA USE AGREEMENT
DUA #
AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
DATA CONTAINING INDIVIDUAL-SPECIFIC INFORMATION
In order to secure Medicare data that resides in a CMS Privacy Act System of Records, and in order to ensure the
integrity, security, and confidentiality of information maintained by CMS, and to permit appropriate disclosure
and use of such data as permitted by law, CMS and the State of _________________________________ enter
into this agreement to comply with the following specific paragraphs.
1. This Agreement is by and between CMS, a component of the U.S. Department of Health and Human
Services (DHHS), and the State of ____________________, hereinafter termed “User.”
2. This Agreement addresses the conditions under which CMS will disclose and the User will obtain and
use the Medicare Long Term Care Minimum Data Set (LTC/MDS) in section 5. This Agreement supersedes
any and all agreements between the parties with respect to the use of the LTC/MDS and preempts and
overrides any instructions, directions, agreements or other prior communication from the Department of
Health and Human Services with respect to the data specified herein. Further, the terms of this Agreement
can be changed only by a written modification to this Agreement, or by the parties adopting a new agreement.
The parties agree further that instructions or interpretations issued to the User concerning this Agreement
or the data specified herein, shall not be valid unless issued in writing by the CMS point-of-contact specified
in section 16, or the CMS signatory to this Agreement shown in section 16. CMS reserves the right to
terminate this agreement at any time if there is evidence that: (1) the agreement is not being complied
with; (2) there is a violation of law in the manner of compliance; or (3) the agreement no longer complies
with changes to statutory or regulatory requirements. Upon such notice, CMS will cease releasing data to
the User under this Agreement and will notify the User either to return all previously released data files
to CMS at the User’s expense or destroy such data.
3. The parties mutually agree that CMS retains all ownership rights to the data file(s) referred to in this
Agreement, and that the User does not obtain any right, title, or interest in any of the data furnished by CMS.
4. The User represents, and in furnishing the Medicare LTC/MDS, CMS relies upon such representation,
that this file(s) will be used solely for the purpose(s) outlined below.
To facilitate the administration of a Federal health program for the purposes of determining participation
requirements, evaluating and/or assessing cost effectiveness, and/or the quality of health care services
provided, and/or for setting long term care Nursing Facility reimbursement rates in the State that are
directly related to the administration of the State Medicaid Program. To facilitate State compliance
with the requirements of the Americans with Disabilities Act.
The User shall not, unless explicitly provided for under contract, disclose, release, reveal, show, sell, rent,
lease, loan, or otherwise grant access to the data covered by this Agreement to any person(s). The User
agrees that, within the User organization, access to the data covered by this Agreement shall be limited to
the minimum number of individuals necessary to achieve the purpose stated in this section. The User
may issue reports, based on data covered by this Agreement, that are directly related to the administration
of the State Medicaid Program to the specific long term care Nursing Facility that has submitted the data.
5. The following file(s) and timeframe are covered under this Agreement:
File
Year(s)
LTC/MDS Resident Assessment Data Files(s)
Form CMS-R-0235M (07/07) EF 07/2007
3

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