Form Cms-R-0235l - Agreement For Use Of Centers For Medicare & Medicaid Services (Cms) Limited Data Sets Page 5

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16. The disclosure provision(s) that allow(s) the discretionary release of CMS data for the purpose(s) stated
in section 3 follow(s). (To be completed by CMS staff.)_______________________________________
17. The undersigned individual hereby attest that they are authorized to enter into this Agreement on behalf
of CMS and agree to all the terms specified herein. (To be completed by CMS staff.)
Name of CMS Representative
(typed or printed)
Title/Component
Mail Stop
Street Address
City
State
ZIP Code
Office Telephone
E-Mail Address
(Include Area Code)
(If applicable)
Signature
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.
Form CMS-R-0235L (02/08)
5

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