Form Cms-R-0235l - Agreement For Use Of Centers For Medicare & Medicaid Services (Cms) Limited Data Sets 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)
LIMITED DATA SETS
In order to ensure that the disclosure and use of Limited Data Sets derived from a CMS Privacy Act
System of Records comply with the Privacy Act of 1974 (5 U.S.C. § 522a) and the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) Privacy Rule (45 C.F.R. Parts 160 and 164), CMS and
________________________________________________________________ enter into this Agreement:
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 (DHHS), and ____________________________
________________________________________, hereinafter termed “User.”
2. The parties mutually agree that CMS retains all ownership rights to the limited data set 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. The parties further agree that CMS makes no representation or warranty, either implied or
express, with respect to the accuracy of any data in the limited data set file(s).
3. The User represents that the limited data set files in section 4 above will be used solely for the following
research purpose (provide a brief summary of the purpose below):
Name of Study/Project
CMS Contract No.
(If applicable)
The User must provide a detailed explanation of the research purpose which is incorporated by reference
into this Agreement. The research purpose must demonstrate the potential to improve the quality of life
for Medicare beneficiaries or improve the administration of the Medicare program, including payment-
related projects. The User represents further that the facts and statements made in this explanation are complete
and accurate. Research Application Guidelines are attached as ‘Attachment A’ and are incorporated by
reference to this Agreement.
4. The following CMS limited data set file(s) is/are covered under this Agreement.
File
Year(s)
Form CMS-R-0235L (02/08)
2

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