CMS-R-235 CMS-R-235.Tab_2j

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

Form Approved
OMB No. 0938-0734

DATA USE AGREEMENT (DUA) UPDATE for Data Acquired from the
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
EXISTING DUA # _____________
1.

The following additional CMS data files(s) are being requested under this Agreement.
Files
Years
System of Record
(to be completed by CMS)

_______________________________________________

__________________

___________________

_______________________________________________

__________________

___________________

_______________________________________________

__________________

___________________

_______________________________________________

__________________

___________________

_______________________________________________

__________________

___________________

2.

On behalf of the user the undersigned individual hereby attests that he or she is authorized to legally
bind the user to the terms of the existing agreement and agrees to all the terms specified therein.

a. Name of Individual
b. Company/Organization
d. Street Address
e. City
i. Signature of Individual

c. E-Mail address
f. State

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

g. Zip Code

h. Phone #
j. Date

13. Signature

14. Date

Please sign and send this certificate as an email attachment 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-0235u (04/11)