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 CONTAINING INDIVIDUAL-SPECIFIC INFORMATION 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 containing individual identifiers. 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 Signature of CMS System Manager or Business Owner Date Date Date Date System Name System Name System Name 1 American LegalNet, Inc. www.USCourtForms.com J Concur J Nonconcur Signature of CMS System Manager or Business Owner J Concur J Nonconcur Signature of CMS System Manager or Business Owner J Concur J Nonconcur Form CMS-R-0235U (11/05) EF 11/2005