Form CMS-10252 CMS-10252. Draft Revised DUA

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

Form Approved
OMB No. 0938-1046

DATA USE AGREEMENT (DUA) CERTIFICATE OF DISPOSITION (COD) for Data Acquired from the
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
This certificate is to be completed and submitted to CMS to certify the destruction/discontinued use of all CMS
data covered by the listed Date Use Agreement (DUA). This includes any and all original files, copies made of
the files, any derivatives or subsets of the files and any manipulated files. The requester may not keep any
copies, derivatives or manipulated files – all files must be destroyed or properly approved for continued use
under another DUA. CMS will close the listed DUA upon receipt and review of this certificate.
Directions for the completion of the certificate:
Item # 1
Provide the Requestor’s Organization
Item # 2
Provide the DUA #
Item # 3
Initial and complete as applicable regarding the disposition of the DUA
Item # 4
List exactly as identified in the DUA all original files and applicable years that were requested
under this DUA.
Item # 5
Fill in the DUA #
Item # 6
Print name of individual signing the form
Item # 7
Signature (must be individual listed in item # 6)
Item # 8
Date signed
Item # 9
Phone # of individual signing the form
Item # 10
E-mail address of individual signing the form
Item # 11
(optional) Alternate point of contact name, phone # and e-mail address
Please sign and send this form as a .pdf scanned attachment in an email 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 0938-1046. 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-10252 v2.0 (1/11)

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

CMS use only
closed by
date closed

DATA USE AGREEMENT (DUA) CERTIFICATE OF DISPOSITION (COD) for Data Acquired from the
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
1. Requestor’s Organization ____________________________________________ DUA # ______________
3. Initial only one item below:
a. _________
(initial)

b. _________
(initial)

c. _________
(initial)

d. _________

All originally requested files and the copies, derivatives, subsets and manipulated files
have been approved _______________ by CMS for re-use in DUA # _____________
(date)
(if more than one DUA, only list 1 DUA #)
Some originally requested files or copies, derivatives, subsets and/or manipulated files
have been approved for re-use by CMS in the DUA(s) per the attached separate sheet.
List the file(s) and year(s) (exactly as listed in the DUA), type of file(s) (e.g. original,
copies, derivatives, subsets and/or manipulated), date approved and re-use DUA #s.
All originally requested files and, as applicable, copies, derivatives, subsets and
manipulated files have been destroyed by all individuals who had access to, and from
all the computers/storage devices where the files were processed/stored in
accordance with the terms and conditions of the DUA.
None of the requested files were ever received/accessed.

(initial)

4. List exactly as identified in the DUA all original files and applicable years that were requested under this
DUA.
File(s)

Year(s)

___________________________________________________________________

__________________

___________________________________________________________________

__________________

___________________________________________________________________

__________________

___________________________________________________________________

__________________

___________________________________________________________________

__________________

___________________________________________________________________

__________________

___________________________________________________________________

__________________

5. By signing this Certificate, I confirm that ALL data requested under DUA # __________ and, as applicable,
copies, derivatives, subsets and manipulated files have been properly disposed of as indicated by my
initials in section 3 above.
6. Printed Name __________________ 7. Signature ____________________________ 8. Date ___________
9. Phone # _______________________ 10. E-mail address _________________________________________
11. (optional) Alternate point of contact Name, phone and e-mail address _____________________________

Form CMS-10252 v2.0 (1/11)

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