Form Cms-R-0235u - Data Use Agreement (Dua)- Update To Existing Dua - Agreement For Use Of Centers For Medicare & Medicaid Services (Cms) Data

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0734
DATA USE AGREEMENT
UPDATE TO EXISTING DATA USE AGREEMENT
EXISTING DUA #
AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) DATA
This agreement is needed as part of the review of your data request to ensure compliance with the requirements
of the Privacy Act, and must be completed prior to the release or use of specified data files.
1. Requestor Organization
2. Name of Study/Project
CMS Contract Number (if applicable)
3. The following additional CMS data files(s) are being requested under this Agreement.
File
Year(s)
System of Record
(to be completed by CMS Staff)
__________________________________________ ___________ ________________________________
__________________________________________ ___________ ________________________________
__________________________________________ ___________ ________________________________
__________________________________________ ___________ ________________________________
__________________________________________ ___________ ________________________________
__________________________________________ ___________ ________________________________
4. On behalf of the user the undersigned individual hereby attests that he or she is authorized to legally bind
the user to the terms of the existing agreement and agrees to all the terms specified therein.
Type or Print Name of Requesting Individual
Signature
Date
5. 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.
Type or Print Name and Title of CMS Representative
Signature
Date
Signature of CMS System Manager or Business Owner
Date
System Name
Concur
Nonconcur
Signature of CMS System Manager or Business Owner
Date
System Name
Concur
Nonconcur
Signature of CMS System Manager or Business Owner
Date
System Name
Concur
Nonconcur
Form CMS-R-0235U (01/10)

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