Form Cms-R-0235d2 - Dsh Data Use Agreement For Cost Reporting Periods That Include December 8, 2004 And Therafter Page 6
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616. The parties mutually agree that the following named individual(s) and/or entities is or are designated as
Custodian(s) of the file(s) on behalf of User and each person or entity so designated will be responsible
for the observance of all conditions of use and for establishment and maintenance of security arrangements
as specified in this Agreement to prevent unauthorized use. User is responsible for any non-observance
of the conditions of use, and/or failure to establish or maintain security arrangements, on the part of any
Custodian. User agrees to notify CMS within fifteen (15) days of any change of custodianship. The parties
mutually agree that CMS may disapprove the appointment of a custodian or may require the appointment
of a new custodian at any time.
Each Custodian agrees and in his or her capacity as an employee or contractor (including consultant,
attorney or other representative) of the User to comply with all of the provisions of this Agreement on
behalf of User.
Name of Custodian
(typed or printed)
Company/Organization
Street Address
City
State
ZIP Code
Office Telephone
E-Mail Address
(Include Area Code)
(If applicable)
Signature
Date
17. The parties mutually agree that the following named individual will be designated as point-of-contact for
the Agreement on behalf of CMS.
On behalf of CMS the undersigned individual hereby attests that he or she is authorized to enter into this
Agreement and agrees to all the terms specified herein.
Name of CMS Representative
JoAnn Cerne
Title/Component
Health Insurance Specialist, CMM, Division of Acute Care
Street Address
Mail Stop
7500 Security Boulevard
C4-08-06
City
State
ZIP Code
Baltimore
MD
21244-1850
Office Telephone
E-Mail Address
(Include Area Code)
(If applicable)
410-786-4530
Joann.Cerne@cms.hhs.gov
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, N2-14-26, Baltimore, Maryland 21244-1850 and to the Office of Information and Regulatory Affairs, Office of Management and Budget,
Washington, D.C. 20503.
Form CMS-R-0235D2 (12/09)
6
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