Form Cms-R-0235l - Agreement For Use Of Centers For Medicare & Medicaid Services (Cms) Limited Data Sets Page 4

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11. The User shall promptly report to CMS any use or disclosure of the information not provided for by this
Data Use Agreement of which it becomes aware. CMS in its sole discretion may require the User to: (a)
promptly investigate and respond to CMS concerns regarding any alleged disclosure; (b) promptly
resolve any problems identified by the investigation; (c) submit a corrective action plan with steps
designed to prevent any future unauthorized disclosures; and/or (d) require that all limited data set files
be immediately returned.
12. The User acknowledges that penalties under § 1106(a) of the Social Security Act [42 U.S.C. § 1306(a)],
including possible imprisonment, may apply with respect to any disclosure of information in the files(s)
that is inconsistent with the terms of the Agreement. The User further acknowledges that criminal penalties
under the Privacy Act [5 U.S.C. § 552a(i)(3)] apply if it is determined that the User, or any individual
employed or affiliated therewith, knowingly and willfully obtained the file(s) under false pretenses. The
User also acknowledges that criminal penalties may be imposed under 18 U.S.C. § 641.
13. By signing this Agreement, the User agrees to abide by all provisions set out in this Agreement for protection
of the limited data set file(s) specified in section 4, and acknowledges having received notice of potential
criminal, civil, and/or administrative penalties for violation of the terms of the Agreement.
14. The undersigned individual hereby attests that he or she is authorized to enter into this Agreement on
behalf of the User and agrees to all the terms specified herein.
Name and Title of User
(typed or printed)
Company/Organization
Street Address
City
State
ZIP Code
Telephone
E-Mail Address
(Include Area Code)
(If applicable)
Signature
Date
15. The parties mutually agree that the following named individual is designated as Custodian of the limited
data set file(s) on behalf of the User and the person shall oversee and comply to the observance of all
conditions of use and the 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.
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-0235L (02/08)
4

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