Form Cms-R-0235d2 - Dsh Data Use Agreement For Cost Reporting Periods That Include December 8, 2004 And Therafter

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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 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 The MEDPAR data that will be provided will be the data file that was used to calculate the
User’s Medicare fraction of the disproportionate patient percentage for the period covered by the request
for a provider’s cost year. CMS will specify the routine use under which the data are being requested.
• Paragraph 6, is to be completed by the User to indicate how long the data will be retained (the retention
date must not exceed 5 years however, CMS will extend the retention date at the request of the User for
good cause shown).
• Paragraph 11 will be completed by the User.
• Paragraph 15 is to be completed by the User.
• Paragraph 16, 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 an appeal on behalf of the User-Provider). This paragraph should be
completed even if the Custodian and the User are the same. Where more than one Custodian is listed,
the data will be sent 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 Custodian(s) for their files.
Form CMS-R-0235D2 (12/09)
1

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