Form Cms-R-0235d1 - Dsh Data Use Agreement For Cost Reporting Periods Prior To Those That Include December 8, 2004

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
INSTRUCTIONS FOR COMPLETING THE DISPROPORTIONATE
SHARE HOSPITAL DATA USE AGREEMENT (DUA)
(AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES
(CMS) DATA CONTAINING INDIVIDUAL IDENTIFIERS)
This agreement is needed as part of the review of your data request to ensure compliance to the requirements
of the Privacy Act, and must be completed prior to the release of specified data files containing individual identifiers.
Directions for the completion of the agreement follow:
Before completing the DUA, please note the language contained in this agreement cannot be altered in
any form.
• Introductory paragraph, enter the User’s Organization Name (Provider Name and Provider Number).
• Enter one (1) PRRB Case No. per DUA. Paragraph 1, enter the User’s Organization Name (Provider
Name and Medicare Provider Number).
• Paragraph 4 specifies the limited permissible use of the data and the persons and/or entities to whom
redisclosure may be made.
• Paragraph 5 Unless unavailable, the update version of the MEDPAR file that will be provided will be the
update that was used to calculate the User’s disproportionate patient percentages for the period covered by
the request (e.g., the June 1997 update version of the FFY 1996 MEDPAR file) for a provider’s cost year.
• Paragraph 11 will be completed by User.
• Paragraph 15 is to be completed by the User.
• Paragraph 16 is to be completed by Custodian. Enter the Custodian Name, Company/Organization,
Address, Phone Number (including area code), and E-Mail Address (if applicable). The Custodian of files
is defined as that entity or person who will have actual possession of and responsibility for the data files
(such as a consulting firm and/or attorney who is prosecuting the appeal on behalf of the User-Provider).
This paragraph should be completed even if the Custodian and Requestor/User are the same. Where
more than one Custodian is listed, the data will be mailed to the first one listed.
Once the DUA is received and reviewed for privacy issues, a completed and signed copy will be sent to the
User and consultant(s) for their files.
Form CMS-R-0235D1 (12/09)
1

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