QE Signature Addendum_JobAid

Instructions for completing the Qualified Entity (QE) NDTR
Signature Addendum
This document: All QE Non-DUA Tracking (NDTR) requests must include a completed QE NDTR Signature

Addendum if adding or replacing a user on a NDTR.

General Instructions

1. Answer every item in the document.
2. Do not alter the layout or content of the document.
3. Submit to the CMS QE Program Contacts, and the QECP mailbox in PDF format.

Specific Instructions

A

Enter your NDTR number if completing
this form for an amendment request. If
submitting a new request, leave blank.

B

Enter the exact Study Title listed on
the NDTR if completing this form for an
amendment request. If submitting a
new request, enter the exact Study Title
listed on the QE form.

C

Select your user role from the dropdown menu.

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

Qualified Entity (QE) NDTR SIGNATURE ADDENDUM FOR DATA ACQUIRED
FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
Complete this form if you are adding one of the following users to the data use agreement:
• Data Custodian: Individual who will be responsible for ensuring that the environment in which the CMS data is stored
complies all applicable CMS data security requirements, including the establishment and maintenance of security
arrangements to prevent unauthorized use. Please note, CMS requires only one data custodian per data
environment.
• Data Recipient: An individual under the oversight of the Data Custodian that will receive physical shipment or virtual
download of CMS data.
Important Notes:
• All form fields are required.
• CMS does not require this form for updates to existing contact information (e.g., e-mail address, phone numbers), but only to add
an individual who is not already on the DUA.
• CMS does not accept mailbox rental services (P.O. Box, UPS Store, etc.) for an address.
• CMS does not accept foreign addresses outside of the United States and its territories.
• CMS does not accept personal e-mail addresses (@yahoo, @gmail, @outlook, etc.). Your e-mail must be associated with your
employer, organization, or university.
• All CMS data must physically remain within the boundaries of the United States and its territories.

A

DUA Number:

Name of Study/Project:

B

Ext.:

Phone:

Name:

F

Organization:
Street Address:
City:
Email:

(Instructions continue on page 2)

Instructions for completing the QE NDTR Signature Addendum |
1

State:

Zip:

H

By signing this form, you are attesting to the terms and conditions defined in the original Data Use Agreement (DUA) documentation.

Signature:

I

D

Enter the name of the contact being
added.

E

Enter the contact’s phone number.

F
Enter the exact legal name of the
contact’s organization.

G
Enter the physical address for the
contact. CMS will not accept PO boxes,
residential addresses, or foreign
addresses.

H
Enter the contact’s email address
associated with an employer or
organization. CMS will not accept
personal email addresses (e.g.,
gmail.com or Hotmail.com).

I
Please sign the form here.

Instructions for completing the QE NDTR Signature Addendum |
2

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

Qualified Entity (QE) NDTR SIGNATURE ADDENDUM FOR DATA ACQUIRED
FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
Complete this form if you are adding one of the following users to the data use agreement:
• Data Custodian: Individual who will be responsible for ensuring that the environment in which the CMS data is stored
complies all applicable CMS data security requirements, including the establishment and maintenance of security
arrangements to prevent unauthorized use. Please note, CMS requires only one data custodian per data
environment.
• Data Recipient: An individual under the oversight of the Data Custodian that will receive physical shipment or virtual
download of CMS data.
Important Notes:
• All form fields are required.
• CMS does not require this form for updates to existing Requester or Data Custodian contact information (e.g., e-mail
address, phone numbers), but only to add an individual who is not already on the DUA.
• CMS does not accept mailbox rental services (P.O. Box, UPS Store, etc.) for an address.
• CMS does not accept foreign addresses outside of the United States and its territories.
•
• with your employer, organization, or university.
• All CMS data must physically remain within the boundaries of the United States and its territories.