Data Use Agreement (DUA) Update To Existing Data Use Agreement
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Data Use Agreement (DUA) Update To Existing Data Use Agreement Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: Data Use Agreement (DUA) Update To Existing Data Use Agreement, CMS-R-0235U, 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
UPDATE TO EXISTING DATA USE AGREEMENT
EXISTING DUA #
AGREEMENT FOR USE OF
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
DATA
This agreement is needed as part of the review of your data request to ensure compliance with the requirements
of the Privacy Act, and must be completed prior to the release or use of specified data files.
1. Requestor Organization
2. Name of Study/Project
CMS Contract Number (if applicable)
3. The following CMS data file(s) is/are covered under this Agreement.
File
Year(s)
System of Record
(to be completed by CMS Staff)
__________________________________________ ____________ ________________________________
__________________________________________ ____________ ________________________________
__________________________________________ ____________ ________________________________
__________________________________________ ____________ ________________________________
__________________________________________ ____________ ________________________________
__________________________________________ ____________ ________________________________
4. On behalf of the user the undersigned individual hereby attests that he or she is authorized to legally bind
the user to the terms of the existing agreement and agrees to all the terms specified herein.
Type or Print Name of Requesting Individual
Signature
Date
5. On behalf of CMS the undersigned individual hereby attests that he or she is authorized to enter into this
Agreement and agrees to all the terms specified herein.
Type or Print Name and Title of CMS Representative
Signature
Date
❏ Concur ❏ Nonconcur
Signature of CMS System Manager or Business Owner
Date
System Name
Signature of CMS System Manager or Business Owner
❏ Concur ❏ Nonconcur
Date
System Name
Signature of CMS System Manager or Business Owner
Date
System Name
❏ Concur ❏ Nonconcur
Form CMS-R-0235U (06/08) EF (06/08)
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