DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES INSTRUCTIONS FOR COMPLETING THE DISPROPORTIONATE SHARE HOSPITAL DATA USE AGREEMENT (DUA) (AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) DATA CONTAINING INDIVIDUAL IDENTIFIERS) This agreement is needed as part of the review of your data request to ensure compliance to the requirements of the Privacy Act, and must be completed prior to the release of specified data files containing individual identifiers. Directions for the completion of the agreement follow: Before completing the DUA, please note the language contained in this agreement cannot be altered in any form. · Introductoryparagraph,entertheUser'sOrganizationName(ProviderNameandProviderNumber). · EnterParagraph1,entertheUser'sOrganizationName(ProviderNameandMedicareProviderNumber). · Paragraph4specifiesthelimitedpermissibleuseofthedataandthepersonsand/orentitiestowhom redisclosure may be made. · Paragraph5TheMEDPARdatathatwillbeprovidedwillbethedatafilethatwasusedtocalculatethe User'sMedicarefractionofthedisproportionatepatientpercentagefortheperiodcoveredbytherequest foraprovider'scostyear.CMSwillspecifytheroutineuseunderwhichthedataarebeingrequested. · Paragraph6,istobecompletedbytheUsertoindicatehowlongthedatawillberetained(theretention datemustnotexceed5yearshowever,CMSwillextendtheretentiondateattherequestoftheUserfor goodcauseshown). · Paragraph11willbecompletedbytheUser. · Paragraph15istobecompletedbytheUser. · Paragraph16,entertheCustodianName,Company/Organization,Address,PhoneNumber(including areacode),andE-MailAddress(ifapplicable).TheCustodianoffilesisdefinedasthatentityorperson who willhaveactualpossessionofandresponsibilityforthedatafiles(suchasaconsultingfirmand/or attorneywhoisprosecutinganappealonbehalfoftheUser-Provider).This paragraph should be completed even if the Custodian and the User are the same.WheremorethanoneCustodianislisted, the data will be sent to the first one listed. OncetheDUAisreceivedandreviewedforprivacyissues,acompletedandsignedcopywillbesenttothe UserandCustodian(s)fortheirfiles. Form CMS-R-0235D2 (12/09) American LegalNet, Inc. www.FormsWorkFlow.com 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0734 DSH DATA USE AGREEMENT FOR COST REPORTING PERIODS THAT INCLUDE DECEMBER 8, 2004 AND THEREAFTER DUA # AGREEMENT FOR USE OF CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) DATA CONTAINING INDIVIDUAL-SPECIFIC INFORMATION InordertosecuredatathatresidesinaCMSPrivacyActSystemofRecords,andinordertoensuretheintegrity, security,andconfidentialityofinformationmaintainedbytheCMS,andtopermitappropriatedisclosureanduse ofsuchdataaspermittedbylaw,CMSand ________________________________________________ enter (Provider Name and Number) into this agreement to comply with the following specific paragraphs. 1. ThisAgreementisbyandbetweentheCentersforMedicare&MedicaidServices(CMS),acomponent oftheU.S.DepartmentofHealthandHumanServices(DHHS),and ____________________________ (Provider Name and Number) _______________________________ ,hereinaftertermed"User." (Provider Name and Number) 2.ThisAgreementaddressestheconditionsunderwhichCMSwilldiscloseandUserwillobtainand usetheCMSdatafile(s)specifiedinparagraph5.ThisAgreementsupersedesanyandallagreements betweenthepartieswithrespecttotheuseofdatafromthefilesspecifiedinparagraph5andpreempts and overrides any instructions, directions, agreements, or other understanding in or pertaining to any grantawardorotherpriorcommunicationfromtheDepartmentofHealthandHumanServicesorany of its components with respect to the data specified herein. Further, the terms of this Agreement can be changed only by a written modification to this Agreement or by the parties adopting a new agreement. ThepartiesagreefurtherthatinstructionsorinterpretationsissuedtoUserconcerningthisAgreementor thedataspecifiedherein,shallnotbevalidunlessissuedinwritingbytheCMSpoint-of-contactspecified inparagraph16ortheCMSsignatorytothisAgreementshowninparagraph17. 3. ThepartiesmutuallyagreethatCMSretainsallownershiprightstothedatafile(s)referredtointhis Agreement,andthatUserdoesnotobtainanyright,title,orinterestinanyofthedatafurnishedbyCMS. 4. Userrepresents,andinfurnishingthedatafile(s)specifiedinparagraph5.CMSreliesuponsuch representation,thatsuchdatafile(s)willbeusedsolelyforthepurposeofcalculatingUser'sMedicare fractionofthedisproportionatepatientpercentage.UserrepresentsfurtherthatUsershallnotdisclose, release, reveal, show, sell, rent, lease, loan, or otherwise grant access to the data covered by this Agreementtoanyperson.Exception:Usermaydisclose,release,revealorshowindividuallyidentifiable datatothefollowingentities(includingindividualsemployedbyorundercontractwithsuchentities) andindividuals,totheextentnecessarytocalculateUser'sMedicarefractionofthedisproportionate patientpercentage:(1)CMS;(2)afiscalintermediaryundercontractwithCMS;(3)ThePRRB;(4)a consultantorattorneyorotherrepresentativeundercontractwithUsertoprosecute,orassistintheprosecution of,anadministrativeand/orjudicialappealofCMS'scalculationofitsdisproportionatepatientpercentage; (5)theDepartmentofJustice(6)aFederalcourt.AnysuchgrantofaccessbyUsertoindividually identifiabledataundertheforegoingExceptionshallbestrictlylimitedtotheextentnecessaryforUser tocalculateitsMedicarefractionofthedisproportionatepatientpercentage­Userisexpectedtoredact individuallyidentifiabledataand/orusecodeidentifierswhereverpossible.Userfurtheragreesthat, withintheUserorganization,accesstothedatacoveredbythisAgreementshallbelimitedtotheminimum number of individuals necessary to achieve the purpose stated in this section paragraph and to those individualsonaneed-to-knowbasisonly. Form CMS-R-0235D2 (12/09) American LegalNet, Inc. www.FormsWorkFlow.com 2 5. ThefollowingCMSdatafile(s)is/arecoveredunderthisAgreement: MEDPARFileExtract Provider Number Provider Cost Reporting Period Theabovefile(s)arebeingdisclosedtoUserunderroutineuse3ofthe`MedicareProviderAnalysis andReview(MEDPAR),HHS/CMS/OIS,09-70-0514'PrivacyActsystemofrecords,publishedat 71Fed.Reg.17470(April06,2006). 6. Thepartiesmutuallyagreethattheaforesaidfile(s)(and/oranyderivativefile(s)(whichincludesany filethatmaintainsorcontinuesidentificationofindividuals))mayberetainedbyUsernomorethan90 daysafterthedateofterminationofUser'sappealofCMS'scalculationofitsdisproportionatepatient percentage.Forpurposesofthisparagraph,"dateofterminationofUser's