Form Cms-R-0235 - Agreement For Use Of Centers For Medicare & Medicaid Services (Cms) Data Containing Individual Identifiers Page 2

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0734
DATA USE AGREEMENT
DUA #
(AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
DATA CONTAINING INDIVIDUAL IDENTIFIERS)
CMS agrees to provide the User with data that reside in a CMS Privacy Act System of Records as identified in this
Agreement. In exchange, the User agrees to pay any applicable fees; the User agrees to use the data only for purposes
that support the User’s study, research or project referenced in this Agreement, which has been determined by CMS to
provide assistance to CMS in monitoring, managing and improving the Medicare and Medicaid programs or the services
provided to beneficiaries; and the User agrees to ensure the integrity, security, and confidentiality of the data by complying
with the terms of this Agreement and applicable law, including the Privacy Act and the Health Insurance Portability and
Accountability Act. In order to secure data that reside in a CMS Privacy Act System of Records; in order to ensure the
integrity, security, and confidentiality of information maintained by the CMS; and to permit appropriate disclosure and use
of such data as permitted by law, CMS and _________________________________________________ enter into this
agreement to comply with the following specific paragraphs.
(Requestor)
1. This Agreement is by and between the Centers for Medicare & Medicaid Services (CMS), a component of the
U.S. Department of Health and Human Services (HHS), and __________________________________________,
(Requestor)
hereinafter termed “User.”
2. This Agreement addresses the conditions under which CMS will disclose and the User will obtain, use, reuse
and disclose the CMS data file(s) specified in section 5 and/or any derivative file(s) that contain direct individual
identifiers or elements that can be used in concert with other information to identify individuals. This Agreement
supersedes any and all agreements between the parties with respect to the use of data from the files specified
in section 5 and preempts and overrides any instructions, directions, agreements, or other understanding in or
pertaining to any grant award or other prior communication from the Department of Health and Human Services
or any of its components 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 or the CMS signatory to this
Agreement shown in section 20.
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 data file(s) specified in section 5 CMS relies upon such
representation, that such data file(s) will be used solely for the following purpose(s).
Name of Study/Project
CMS Contract No.
(If applicable)
The User represents further that the facts and statements made in any study or research protocol or project plan
submitted to CMS for each purpose are complete and accurate. Further, the User represents that said study
protocol(s) or project plans, that have been approved by CMS or other appropriate entity as CMS may determine,
represent the total use(s) to which the data file(s) specified in section 5 will be put.
The User agrees not to disclose, use or reuse the data covered by this agreement except as specified in an
Attachment to this Agreement or except as CMS shall authorize in writing or as otherwise required by law, sell,
rent, lease, loan, or otherwise grant access to the data covered by this Agreement. The User affirms that the
requested data is the minimum necessary to achieve the purposes stated in this section. The User agrees that,
within the User organization and the organizations of its agents, access to the data covered by this Agreement
shall be limited to the minimum amount of data and minimum number of individuals necessary to achieve the
purpose stated in this section (i.e., individual’s access to the data will be on a need-to-know basis).
Form CMS-R-0235 (06/10)
2

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