Addendum To The Medicaid Agency Data Use Agreement (DUA)
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Addendum To The Medicaid Agency 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 The Medicaid Agency Data Use Agreement (DUA), CMS-R-0235MA, Official Federal Forms Centers For Medicare And Medicaid Services,
Form Approved
OMB No. 0938-0734
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
ADDENDUM TO THE MEDICAID AGENCY DATA USE AGREEMENT (DUA)
Addendum to DUA for _________________________. If this is an addendum to a previously approved DUA,
insert the CMS assigned DUA number here: __________. The following individual(s) may/will have access to
the CMS data that is being requested for Title II ADA/Olmstead activities. Their signatures attest to their
agreement to the terms of this Data User Agreement:
Note: Some existing DUAs do not contain the following language under Item #4: “To facilitate State
compliance with the requirements of the Americans with Disabilities Act.” For these DUAs, a
custodian must be added below.
Name and Title of Individual
(typed or printed)
Task / Role of this individual in this project
Company / Organization
Street Address
City
State
ZIP Code
Office Telephone (Include Area Code)
E-Mail Address
Signature of Individual
Date
Signature of CMS Representative
Date
Signature of CMS Representative
Date
Name and Title of Individual
(If applicable)
(typed or printed)
Task / Role of this individual in this project
Company / Organization
Street Address
City
State
ZIP Code
Office Telephone (Include Area Code)
E-Mail Address
Signature of Individual
Date
Signature of CMS Representative
Date
Signature of CMS Representative
Date
(If applicable)
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 30 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 any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: Reports Clearance Officer, Baltimore,
Maryland 21244-1850.
Form CMS-R-0235MA (03/06) EF 03/2006
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