CMS-R-235 CMS-R-235.Tab_2b

Department of Health and Human Services (DHHS)
Centers for Medicare & Medicaid Services (CMS)

Form Approved
OMB No. 0938-0734

DATA USE AGREEMENT (DUA) ADDENDUM for Data Acquired from the
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
The following individual(s) requests access to CMS data. Their signature(s) attest to their agreement with the
terms and conditions defined in the original documentation for Data Use Agreement (DUA) ___________ or
for new DUA study/project name _____________________________________________________________.
Part A
1. Name of Individual

3.
5.
6.
10.

Company/Organization
Street Address
City
Signature of Individual

2. Individual’s role(circle all applicable)
Requester / Custodian / Recipient / IDR / DESY
4. E-Mail address
7. State

Part B
1. Name of Individual
3. Company/Organization
5. Street Address
6. City
10. Signature of Individual

For CMS Representative Completion/Approval
12. Name of (circle as applicable)
CMS Project Officer / CMS Privacy Representative

8. Zip Code
9. Phone #
11. Date

2. Individual’s role(circle all applicable)
Requester / Custodian / Recipient / IDR / DESY
4. E-Mail address
7. State

8. Zip Code
9. Phone #
11. Date

13. Signature

14. Date

Please sign, scan and attach to an email and send to [email protected]
or mail to:

Centers for Medicare & Medicaid Services
Director, Division of Information Security & Privacy Management,
OIS-EASG,
Mailstop N1-24-08,
7500 Security Boulevard,
Baltimore, Maryland 21244-1850

Please visit our web site at http://cms.hhs.gov/privprotecteddata
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 5 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-R-0235a (proposed 04/11)