Form Cms-R-0235m - Medicaid Agency Data Use Agreement Page 5

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13. The disclosure provision(s) that allow the discretionary release of CMS data for the purpose(s) stated in
paragraph 4 follow(s).
Long Term Care Minimum Data Set, System of Records #09-70-1517, routine use #2(c)
14. On behalf of the User, the undersigned individual hereby attests that he or she is authorized to enter into
this Agreement and agrees to all the terms specified herein.
Name of User
(typed or printed)
State Agency/Organization
Street Address
City
State
ZIP Code
Office Telephone
E-Mail Address
(Include Area Code)
(If applicable)
Signature
Date
15. The parties mutually agree that the following named individual is designated as “Custodian” of the
file(s) on behalf of the User, and will be responsible for the observance of all conditions of use and for
establishment and maintenance of security arrangements as specified in this Agreement to prevent
unauthorized use. The User agrees to notify CMS within fifteen (15) days of any change of custodianship.
The parties mutually agree that CMS may disapprove the appointment of a custodian, or may require the
appointment of a new custodian at any time.
The Custodian hereby acknowledges his/her appointment as custodian of the aforesaid file(s) on behalf
of the User, and agrees to comply with all of the provisions of this Agreement on behalf of the User.
Name of Custodian
(typed or printed)
Company/Organization
Street Address
City
State
ZIP Code
Office Telephone
E-Mail Address
(Include Area Code)
(If applicable)
Signature
Date
Form CMS-R-0235M (07/07) EF 07/2007
5

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