Form Cms-R-0235 - Agreement For Use Of Centers For Medicare & Medicaid Services (Cms) Data Containing Individual Identifiers Page 5

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14. The User hereby acknowledges that criminal penalties under §1106(a) of the Social Security Act (42 U.S.C.
§ 1306(a)), including a fine not exceeding $10,000 or imprisonment not exceeding 5 years, or both, may apply to
disclosures of information that are covered by § 1106 and that are not authorized by regulation or by Federal law.
The User further acknowledges that criminal penalties under the Privacy Act (5 U.S.C. § 552a(i) (3)) may apply if
it is determined that the Requestor or Custodian, or any individual employed or affiliated therewith, knowingly and
willfully obtained the file(s) under false pretenses. Any person found to have violated sec. (i)(3) of the Privacy Act
shall be guilty of a misdemeanor and fined not more than $5,000. Finally, the User acknowledges that criminal
penalties may be imposed under 18 U.S.C. § 641 if it is determined that the User, or any individual employed or
affiliated therewith, has taken or converted to his own use data file(s), or received the file(s) knowing that they
were stolen or converted. Under such circumstances, they shall be fined under Title 18 or imprisoned not more
than 10 years, or both; but if the value of such property does not exceed the sum of $1,000, they shall be fined
under Title 18 or imprisoned not more than 1 year, or both.
15. By signing this Agreement, the User agrees to abide by all provisions set out in this Agreement and acknowledges
having received notice of potential criminal or administrative penalties for violation of the terms of the Agreement.
16. On behalf of the User the undersigned individual hereby attests that he or she is authorized to legally bind the User
to the terms this Agreement and agrees to all the terms specified herein.
Name and Title of User
(typed or printed)
Company/Organization
Street Address
City
State
ZIP Code
Office Telephone
E-Mail Address
(Include Area Code)
(If applicable)
Signature
Date
17. 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 the person 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-0235 (06/10)
5

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