DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-1046 DATA USE AGREEMENT (DUA) CERTIFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) This certificate is to be completed and submitted to CMS to certify the destruction/discontinued use of all CMS data covered by the listed Data Use Agreement (DUA) at all locations and/or under the control of all individuals with access to the data. This includes any and all original files, copies made of the files, any derivatives or subsets of the files and any manipulated files. The requester may not retain any copies, derivatives or manipulated files � all files must be destroyed or properly approved in writing by CMS for continued use under an additional DUA(s). CMS will close the listed DUA upon receipt and review of this certificate and provide e-mail confirmation to the submitter of the certificate. Directions for the completion of the certificate follow: Item # 1 Item # 2 Item # 3 Item Item Item Item Item Item Item Item # # # # # # # # 4 5 6 7 8 9a 9b 10 Provide the Requester's Organization Provide the DUA # Check only one (1) box regarding the disposition of the DUA. List exactly as identified in the DUA all original files and applicable years associated with this DUA. Certification statement Print name of individual signing the form Phone # of individual signing the form Date signed E-mail address of individual signing the form (optional) Alternate point of contact (POC) name and phone (optional) Alternate POC e-mail Signature (must be individual listed in item # 6) (use entire box for digital signatures if available) If digitally signed, attach the form to an e-mail; otherwise, please sign, scan and attach to an e-mail and send to DataUseAgreement@cms.hhs.gov. For individuals requiring assistance, please send an e-mail to DataUseAgreement@cms.hhs.gov. Please visit our web site at www.cms.gov/privacy for the most current information regarding DUAs including information about digitally signing DUA forms. 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 0938-1046. 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, Maryland 21244-1850. Form CMS-10252 (5/29/12) American LegalNet, Inc. www.FormsWorkFlow.com 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 7500 Security Boulevard Baltimore, Maryland 21244-1850 CMS Use Only Closed by: Date Closed: DATA USE AGREEMENT (DUA) CERTIFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) 1. REQUESTER ORGANIZATION: 2. DATA USE AGREEMENT (DUA) NO.: 3. CHECK ONLY ONE ITEM BELOW: o o a. All requested files and the copies, derivatives, subsets and manipulated files have been approved by CMS for re-use. Attach a copy of the approval documentation. b. Some requested files or copies, derivatives, subsets and/or manipulated files have been approved by CMS for re-use. Attach a copy of the approval documentation and list below the files that were destroyed. c. None of the files were ever received for this DUA. d. All files listed below, received under the DUA # listed above, have been destroyed, including copies, derivatives, subsets and manipulated files. o o File(s) Year(s) 4. By signing this Certificate, I confirm that ALL data requested for the DUA number listed above and as applicable, copies, derivatives, subsets and manipulated files, held by all individuals who had access to, and from all the computers/storage devices where the files were processed/stored in accordance with the terms and conditions of the DUA have been properly disposed of as indicated by section 3 above. 5. PRINTED NAME: 6. PHONE #: 8. E-MAIL: 7. DATE: 9a. (OPTIONAL) ALTERNATE POINT OF CONTACT (POC) NAME AND PHONE: 9b. (OPTIONAL) ALTERNATE POC E-MAIL: Form CMS-10252 (5/29/12) 10. SIGNATURE: 2 American LegalNet, Inc. www.FormsWorkFlow.com