Form Cms-10252 - Data Use Agreement (Dua) Certificate Of Disposition (Cod) For Data Acquired From The Centers For Medicare & Medicaid Services (Cms)
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2DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-1046
DATA USE AGREEMENT (DUA) CERTIFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED
FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
This certificate is to be completed and submitted to CMS to certify the destruction/discontinued use of all CMS
data covered by the listed Data Use Agreement (DUA) at all locations and/or under the control of all individuals
with access to the data. This includes any and all original files, copies made of the files, any derivatives or subsets
of the files and any manipulated files. The requester may not retain any copies, derivatives or manipulated files –
all files must be destroyed or properly approved in writing by CMS for continued use under an additional DUA(s).
CMS will close the listed DUA upon receipt and review of this certificate and provide e-mail confirmation to the
submitter of the certificate.
Directions for the completion of the certificate follow:
Item # 1
Provide the Requester’s Organization
Item # 2
Provide the DUA #
Item # 3
Check only one (1) box regarding the disposition of the DUA. List exactly as
identified in the DUA all original files and applicable years associated with this DUA.
Item # 4
Certification statement
Item # 5
Print name of individual signing the form
Item # 6
Phone # of individual signing the form
Item # 7
Date signed
Item # 8
E-mail address of individual signing the form
Item # 9a
(optional) Alternate point of contact (POC) name and phone
Item # 9b
(optional) Alternate POC e-mail
Item # 10
Signature (must be individual listed in item # 6) (use entire box for digital signatures if available)
If digitally signed, attach the form to an e-mail; otherwise, please sign, scan and attach to an e-mail and
send to DataUseAgreement@cms.hhs.gov. For individuals requiring assistance, please send an e-mail to
DataUseAgreement@cms.hhs.gov.
Please visit our web site at
for the most current information regarding DUAs including
information about digitally signing DUA forms.
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 0938-1046. 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, Maryland 21244-1850.
Form CMS-10252 (5/29/12)
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