Form Cms-R-0235m - Medicaid Agency Data Use Agreement Page 6

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16.The parties mutually agree that the following named individual will be designated as “point-of-contact”
for the Agreement on behalf of CMS.
Name of CMS Contact
(typed or printed)
Title/Component
Street Address
City
State
ZIP Code
Phone Number
E-Mail Address
(Include Area Code)
17. The parties mutually agree that the following named individual will be designated as point-of-contact for
the Agreement on behalf of CMS.
On behalf of CMS 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 CMS Representative
(typed or printed)
Title/Component
Street
Mail Stop
City
State
ZIP Code
Office Telephone
E-Mail Address
(Include Area Code)
(If applicable)
A. Signature
Date
B. Concur/Nonconcur — Signature of CMS System Manager or Business Owner
Date
C. Concur/Nonconcur — Signature of CMS Protocol or Project Review Representative
Date
Form CMS-R-0235M (07/07) EF 07/2007
6

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