CMS-10252, Summary of Changes

CMS-10252 Data Use Agreement Certificate of Disposition
Summary of Changes
Items removed from the previous version
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12.

Requestor name
Requestor address
Requester Phone #
Custodian name
Custodian organization
Custodian address
Custodian phone #
Project/Study Name
CMS Project Officer (PO) name
CMS PO Printed name
CMS PO signature
CMS PO signature date
Items added to the (10/10) version form

13. Provides section numbering for easy of referencing areas on the form
14. Provides directly on the form the statement that .pdf scans are acceptable and where they
should be emailed
15. Requires the signatory to provide an email
16. Specifically directs the signatory’s name to be printed on the form
17. Section 3 now provides for the stipulation that the form is only for closing the entire DUA and
not specific files or a specific individual’s use of the files
18. Section 3a now provides for the precise stipulation that all the data is being re-used in another
DUA
19. Section 3b now provides for the precise stipulation that only some and exactly which data is
being re-used in another DUA
20. Section 3d now provides for certification when data was never received/accessed
21. Provides more room for listing file names
22. Provides more specific instructions on page 1
23. Provides optional place for POC information