Form CMS-10252 CERTIFICATE OF DATA DESTRUCTION

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
omb no. xxxx-xxxx

INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF DATA DESTRUCTION FOR DATA
ACQUIRED FROM the CENTERS FOR MEDICARE & MEDICAID SERVICES
This certificate is to be completed and submitted to CMS to certify the destruction of all CMS data covered by the listed
Data Use Agreement (DUA). This includes any copies made of the files, any derivative or subsets of the files, and any
manipulated files. The requestor may not keep any copies, derivative or manipulated files—all files must be destroyed.
CMS will close the listed DUA upon receipt and review of this certificate.
Directions for the completion of the certificate follow:
n Complete the Requestor and Custodian’s Organization and Contact information as listed in the DUA.
n

Provide the DUA number.

n

Provide the Project/Study Name as listed on the DUA.

n

Provide the CMS Project Officer, if applicable.

n

Please list all data files and years covered by the DUA.

n

A signature is required on this certification. The signature should be the requestor or Custodian listed on the DUA.
If the DUA is for a CMS Contract/Demonstration, the CMS Project Officer must also sign the certificate.

Please submit this certificate to:
Director, Division of Privacy Compliance
Division of Privacy Compliance
Mailstop: N2-04-27
7500 Security Blvd.
Baltimore, MD 21244

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-XXXX. The time required to complete this
information collection is estimated to average (XX hours) or (XX 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 comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Form CMS-10252 (12/07)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
7500 Security Boulevard
Baltimore, Maryland 21244-1850

Certificate of Data Destruction for Data Acquired from
the Centers for Medicare & Medicaid Services
requestor Organization

Data Use Agreement (DUA) No.

requestor Contact Name

Phone No.

requestor Address

Custodian Organization

Custodian Contact Name

Custodian Address

Phone No.

Project/Study Name

CMS Project Officer (if applicable)

CMS Data Files Destroyed:

Files

Years

By signing this Certification of Data Destruction, I confirm that the data acquired under DUA #
been completely destroyed and no copies have been kept.
requestor or Custodian Printed Name

Signature date

CMS Project Officer (if applicable) Printed Name

Signature date

Form CMS-10252 (12/07)

have

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