Form Cms-R-0235d1 - Dsh Data Use Agreement For Cost Reporting Periods Prior To Those That Include December 8, 2004 Page 2

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0734
DSH DATA USE AGREEMENT FOR COST REPORTING PERIODS
PRIOR TO THOSE THAT INCLUDE DECEMBER 8, 2004
DUA #
AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
DATA CONTAINING INDIVIDUAL-SPECIFIC INFORMATION
In order to secure data that resides in a CMS Privacy Act System of Records, and in order to ensure the integrity,
security, and confidentiality of information maintained by the CMS, and to permit appropriate disclosure and
use of such data as permitted by law, CMS and __________________________________________________
(Provider Name and Number)
enter into this agreement to comply with the following specific paragraphs.
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 (HHS), and _____________________________
_____________________________________________ , hereinafter termed “User.” User represents
(Provider Name and Number)
that it currently has pending before the Provider Reimbursement Review Board a jurisdictionally proper
appeal(s) on the issue of the calculation of the User’s ratio of Medicare/SSI days to total Medicare
covered days, (PRRB Case No. ________________________________________ , for the following cost
reporting period(s) __________________________________________________ .
2. This Agreement addresses the conditions under which CMS will disclose and User will obtain and
use the CMS data file(s) specified in paragraph 5. This Agreement supersedes any and all agreements
between the parties with respect to the use of data from the files specified in paragraph 5 and preempts
and overrides any instructions, directions, agreements, or other understanding in or pertaining to any
grant award or other prior communication from the Department of Health and Human Services or any
of its components with respect to the data specified herein. Further, the terms of this Agreement can be
changed only by a written modification to this Agreement or by the parties adopting a new agreement.
The parties agree further that instructions or interpretations issued to User concerning this Agreement or
the data specified herein, shall not be valid unless issued in writing by the CMS point-of-contact specified
in paragraph 16 or the CMS signatory to this Agreement shown in paragraph 17.
3. The parties mutually agree that CMS retains all ownership rights to the data file(s) referred to in this
Agreement, and that User does not obtain any right, title, or interest in any of the data furnished by CMS.
4. User represents, and in furnishing the data file(s) specified in paragraph 5 CMS relies upon such
representation, that such data file(s) will be used solely for the purpose of pursuing an administrative
and/or judicial appeal of CMS’s calculation of User’s disproportionate patient percentage. User represents
further that User shall not disclose, release, reveal, show, sell, rent, lease, loan, or otherwise grant access
to the data covered by this Agreement to any person. Exception: User may disclose, release, reveal or
show individually identifiable data to the following entities (including individuals employed by or under
contract with such entities) and individuals, to the extent necessary to pursue an administrative and/
or judicial appeal of CMS’s calculation of its disproportionate patient percentage: (1) CMS; (2) a fiscal
intermediary under contract with CMS; (3) The PRRB; (4) a consultant or attorney or other representative
under contract with User to prosecute, or assist in the prosecution of, an administrative and/or judicial
appeal of CMS’s calculation of its disproportionate patient percentage; (5) the Department of Justice; (6)
a Federal court. Any such grant of access by User to individually identifiable data under the foregoing
Exception shall be strictly limited to the extent necessary for User to pursue its administrative and/
or judicial appeal of CMS’s calculation of its disproportionate patient percentage—User is expected to
redact individually identifiable data and/or use code indentifiers wherever possible. User further agrees
that, within the User organization, access to the data covered by this Agreement shall be limited to the
minimum number of individuals necessary to achieve the purpose stated in this section paragraph and to
those individuals on a need-to-know basis only.
Form CMS-R-0235D1 (12/09)
2

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