R-0235u. cms-r-0235u

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

Form Approved
OMB No. 0938-0734

DATA USE AGREEMENT
UPDATE TO EXISTING DATA USE AGREEMENT
EXISTING DUA #
AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) DATA
This agreement is needed as part of the review of your data request to ensure compliance with the requirements
of the Privacy Act, and must be completed prior to the release or use of specified data files.
1. Requestor Organization
2. Name of Study/Project
CMS Contract Number (if applicable)

3. The following additional CMS data files(s) are being requested under this Agreement.
File

Year(s)

System of Record
(to be completed by CMS Staff)

__________________________________________

___________

________________________________

__________________________________________

___________

________________________________

__________________________________________

___________

________________________________

__________________________________________

___________

________________________________

__________________________________________

___________

________________________________

__________________________________________

___________

________________________________

4. 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.
Type or Print Name of Requesting Individual
Signature

Date

5. On behalf of CMS the undersigned individual hereby attests that he or she is authorized to enter into this
Agreement and agrees to all the terms specified herein.
Type or Print Name and Title of CMS Representative
Signature

Date

Signature of CMS System Manager or Business Owner

Concur

Date

System Name

Date

System Name

Nonconcur

Signature of CMS System Manager or Business Owner

Concur

System Name

Nonconcur

Signature of CMS System Manager or Business Owner

Concur

Date

Nonconcur

Form CMS-R-0235U (01/10)