Form Cms-R-0235d1 - Dsh Data Use Agreement For Cost Reporting Periods Prior To Those That Include December 8, 2004 Page 3

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5. The following CMS data file(s) is/are covered under this Agreement:
MEDPAR File Extract
Provider Cost
Provider Number
Charge Per Year*
Reporting Period
* For pre-FFY1996, charge is $1,200 per year (FFY or provider cost year), per provider;
$
TOTAL:
For FFY 1996 to present, charge is $900 per year (FFY or provider cost year), per provider;
Where cost year includes part of both FFY 1995 and FFY 1996, charge is $900.
The above file(s) are being disclosed to User under routine use 2 of the “Medicare Provider Analysis
and Review (MEDPAR), HHS/CMS/OIS, 09-70-0514” Privacy Act system of records, published at
71 Fed. Reg. 17470 (April 06, 2006).
6. The parties mutually agree that the aforesaid file(s) (and/or any derivative file(s) (which includes any file
that maintains or continues identification of individuals)) may be retained by User no more than 90 days
after the date of termination of User’s appeal of CMS’s calculation of its disproportionate patient
percentage. For purposes of this paragraph, “date of termination of User’s appeal” shall be the date
upon which any of the following events occur: (1) the User abandons its appeal; (2) an order rendered
by the PRRB, the CMS Administrator or court upholding CMS’s calculation of User’s disproportionate
patient percentage has become final and non-appealable; (3) an order rendered by the PRRB, the CMS
Administrator or court awarding additional payment to User with respect to the disproportionate patient
percentage (including an order approving a settlement) has become final and non-appealable and such
payment has been made to User; (4) an administrative resolution satisfactory to User and to the fiscal
intermediary is reached on the appeal, and any additional payment provided for by such resolution, with
respect to the disproportionate patient percentage, has been made to User. User agrees to destroy the
files(and/or any derivative file(s) (which includes any file that maintains or continues identification of
individuals)) after the date of termination of User’s appeal. User agrees that no data from CMS records,
or any parts thereof, shall be retained when the aforementioned file(s) are destroyed unless authorization
in writing for the retention of such file(s) has been received from the appropriate Systems Manager or
the person designated in paragraph 17 of this Agreement. User acknowledges that strict adherence to the
aforementioned retention date is required.
The Agreement may be terminated by either party at any time for any reason upon 30 days written
notice. Upon such notice, CMS will cease releasing data to User under this Agreement and will notify
User to destroy all previously released data files. Sections 3, 4, 6, 9, 10, 12, 13 and 14 shall survive
termination of this Agreement.
Form CMS-R-0235D1 (12/09)
3

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