Form Cms-R-0235 - Agreement For Use Of Centers For Medicare & Medicaid Services (Cms) Data Containing Individual Identifiers Page 6

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18. The disclosure provision(s) that allows the discretionary release of CMS data for the purpose(s) stated in section 4
follow(s). (To be completed by CMS staff.) _________________________________________
19. On behalf of __________________________________ the undersigned individual hereby acknowledges that
the aforesaid Federal agency sponsors or otherwise supports the User’s request for and use of CMS data, agrees
to support CMS in ensuring that the User maintains and uses CMS’s data in accordance with the terms of this
Agreement, and agrees further to make no statement to the User concerning the interpretation of the terms of this
Agreement and to refer all questions of such interpretation or compliance with the terms of this Agreement to the
CMS official named in section 20 (or to his or her successor).
Typed or Printed Name
Title of Federal Representative
Signature
Date
Office Telephone
E-Mail Address
(Include Area Code)
(If applicable)
20. 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 Address
Mail Stop
City
State
ZIP Code
Office Telephone
E-Mail Address
(Include Area Code)
(If applicable)
A. Signature of CMS Representative
Date
B. Concur/Nonconcur — Signature of CMS System Manager or Business Owner
Date
Concur/Nonconcur — Signature of CMS System Manager or Business Owner
Date
Concur/Nonconcur — Signature of CMS System Manager or Business Owner
Date
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 0938-0734. The time required to complete this information collection is estimated to average 30 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
Reports Clearance Officer, Baltimore, Maryland 21244-1850.
6
Form CMS-R-0235 (06/10)

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