DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES INSTRUCTIONS FOR COMPLETING THE DISPROPORTIONATE SHARE HOSPITAL DATA USE AGREEMENT (DUA) (AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) DATA CONTAINING INDIVIDUAL IDENTIFIERS) This agreement is needed as part of the review of your data request to ensure compliance to the requirements of the Privacy Act, and must be completed prior to the release of specified data files containing individual identifiers. Directions for the completion of the agreement follow: Before completing the DUA, please note the language contained in this agreement cannot be altered in any form. · Introductoryparagraph,entertheUser'sOrganizationName(ProviderNameandProviderNumber). · Enter one (1) PRRB Case No. per DUA.Paragraph1,entertheUser'sOrganizationName(Provider NameandMedicareProviderNumber). · Paragraph4specifiesthelimitedpermissibleuseofthedataandthepersonsand/orentitiestowhom redisclosure may be made. · Paragraph5Unlessunavailable,theupdateversionoftheMEDPARfilethatwillbeprovidedwillbethe updatethatwasusedtocalculatetheUser'sdisproportionatepatientpercentagesfortheperiodcovered by therequest(e.g.,theJune1997updateversionoftheFFY1996MEDPARfile)foraprovider'scostyear. · Paragraph11willbecompletedbyUser. · Paragraph15istobecompletedbytheUser. · Paragraph16istobecompletedbyCustodian.EntertheCustodianName,Company/Organization, Address,PhoneNumber(includingareacode),andE-MailAddress(ifapplicable).TheCustodianoffiles is defined as that entity or person who will have actual possession of and responsibility for the data files (suchasaconsultingfirmand/orattorney whoisprosecutingtheappealonbehalfoftheUser-Provider). This paragraph should be completed even if the Custodian and Requestor/User are the same. Where morethanoneCustodianislisted,thedatawillbemailedtothefirstonelisted. OncetheDUAisreceivedandreviewedforprivacyissues,acompletedandsignedcopywillbesenttothe Userandconsultant(s)fortheirfiles. Form CMS-R-0235D1 (12/09) American LegalNet, Inc. www.FormsWorkFlow.com 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0734 DSH DATA USE AGREEMENT FOR COST REPORTING PERIODS PRIOR TO THOSE THAT INCLUDE DECEMBER 8, 2004 DUA # AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) DATA CONTAINING INDIVIDUAL-SPECIFIC INFORMATION InordertosecuredatathatresidesinaCMSPrivacyActSystemofRecords,andinordertoensuretheintegrity, security,andconfidentialityofinformationmaintainedbytheCMS,andtopermitappropriatedisclosureand useofsuchdataaspermittedbylaw,CMSand__________________________________________________ (Provider Name and Number) enter into this agreement to comply with the following specific paragraphs. 1. ThisAgreementisbyandbetweentheCentersforMedicare&MedicaidServices(CMS),acomponent oftheU.S.DepartmentofHealthandHumanServices(HHS),and_____________________________ _____________________________________________,hereinaftertermed"User."Userrepresents (Provider Name and Number) that itcurrentlyhaspendingbeforetheProviderReimbursementReviewBoardajurisdictionallyproper appeal(s)ontheissueofthecalculationoftheUser'sratioofMedicare/SSIdaystototalMedicare covereddays,(PRRBCaseNo.________________________________________, for the following cost reportingperiod(s)__________________________________________________. 2. ThisAgreementaddressestheconditionsunderwhichCMSwilldiscloseandUserwillobtainand usetheCMSdatafile(s)specifiedinparagraph5.ThisAgreementsupersedesanyandallagreements betweenthepartieswithrespecttotheuseofdatafromthefilesspecifiedinparagraph5andpreempts and overrides any instructions, directions, agreements, or other understanding in or pertaining to any grantawardorotherpriorcommunicationfromtheDepartmentofHealthandHumanServicesorany ofitscomponentswithrespecttothedataspecifiedherein.Further,thetermsofthisAgreementcanbe changed only by a written modification to this Agreement or by the parties adopting a new agreement. ThepartiesagreefurtherthatinstructionsorinterpretationsissuedtoUserconcerningthisAgreementor thedataspecifiedherein,shallnotbevalidunlessissuedinwritingbytheCMSpoint-of-contactspecified inparagraph16ortheCMSsignatorytothisAgreementshowninparagraph17. 3. ThepartiesmutuallyagreethatCMSretainsallownershiprightstothedatafile(s)referredtointhis Agreement,andthatUserdoesnotobtainanyright,title,orinterestinanyofthedatafurnishedbyCMS. 4. Userrepresents,andinfurnishingthedatafile(s)specifiedinparagraph5CMSreliesuponsuch representation,thatsuchdatafile(s)willbeusedsolelyforthepurposeofpursuinganadministrative and/orjudicialappealofCMS'scalculationofUser'sdisproportionatepatientpercentage.Userrepresents furtherthatUsershallnotdisclose,release,reveal,show,sell,rent,lease,loan,orotherwisegrantaccess tothedatacoveredbythisAgreementtoanyperson.Exception:Usermaydisclose,release,revealor showindividuallyidentifiabledatatothefollowingentities(includingindividualsemployedbyorunder contractwithsuchentities)andindividuals,totheextentnecessarytopursueanadministrativeand/ orjudicialappealofCMS'scalculationofitsdisproportionatepatientpercentage:(1)CMS;(2)afiscal intermediaryundercontractwithCMS;(3)ThePRRB;(4)aconsultantorattorneyorotherrepresentative undercontractwithUsertoprosecute,orassistintheprosecutionof,anadministrativeand/orjudicial appealofCMS'scalculationofitsdisproportionatepatientpercentage;(5)theDepartmentofJustice;(6) aFederalcourt.AnysuchgrantofaccessbyUsertoindividuallyidentifiabledataundertheforegoing ExceptionshallbestrictlylimitedtotheextentnecessaryforUsertopursueitsadministrativeand/ orjudicialappealofCMS'scalculationofitsdisproportionatepatientpercentage--Userisexpectedto redactindividuallyidentifiabledataand/orusecodeindentifierswhereverpossible.Userfurtheragrees that,withintheUserorganization,accesstothedatacoveredbythisAgreementshallbelimitedtothe minimum number of individuals necessary to achieve the purpose stated in this section paragraph and to thoseindividualsonaneed-to-knowbasisonly. Form CMS-R-0235D1 (12/09) American LegalNet, Inc. www.FormsWorkFlow.com 2 5. ThefollowingCMSdatafile(s)is/arecoveredunderthisAgreement: MEDPARFileExtract Provider Number Provider Cost Reporting Period Charge Per Year* *Forpre-FFY1996,chargeis$1,200peryear(FFYorprovidercostyear),perprovider; ForFFY1996topresent,chargeis$900peryear(FFYorprovidercostyear),perprovider; WherecostyearincludespartofbothFFY1995andFFY1996,chargeis$900. TOTAL: $ Th