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Addendum To Data Use Agreement (DUA) Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: Addendum To Data Use Agreement (DUA), CMS-R-0235A, Official Federal Forms Centers For Medicare And Medicaid Services,
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0734 DATA USE AGREEMENT (DUA) ADDENDUM for Data Acquired from the CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) The following individual(s) requests access to CMS data. Their signature(s) attest to their agreement with the WHUPV DQG FRQGLWLRQV GHÀQHG LQ WKH RULJLQDO GRFXPHQWDWLRQ IRU 'DWD 8VH $JUHHPHQW '8$ BBBBBBBBBBB RU IRU QHZ '8$ VWXG\SURMHFW QDPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Part A _______ Requester _______ Custodian _______ Subcontractor _______ Recipient 3ULQWHG 1DPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 3KRQH BBBBBBBBBBBBBBBBBBBB ([WBBBBBBBBBBBBBB 2UJDQL]DWLRQ BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 6WUHHW $GGUHVV BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB &LW\ BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB6WDWH BBBBBBBBBBBBB=LS BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB (PDLO BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Signature LI DSSOLFDEOH &RXULHU QDPH BBBBBBBBBBBBBBBBBBBBBBB $FFRXQW QXPEHU BBBBBBBBBBBBBBBBBBBBBBBBBBBBB Part B _______ Requester _______ Custodian _______ Subcontractor _______ Recipient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ÀFHU 5HSUHVHQWDWLYH &25 *RYHUQPHQW 7DVN /HDG *7/ RU &06 3ULYDF\ 6WDII 3ULQWHG 1DPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 6LJQDWXUH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 2UJDQL]DWLRQBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Please send as an email attachment to DataUseAgreement@cms.hhs.gov, DQG VHH RXU ZHEVLWH DW www.cms.gov/privacy 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 10 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, Md. 21244-1850. Form CMS-R-0235A (06/12) American LegalNet, Inc. www.FormsWorkFlow.com
