CMS-R-235 QE DUA Signature Addendum

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

Qualified Entity (QE) DATA USE AGREEMENT (DUA) SIGNATURE ADDENDUM FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

Complete this form if you are adding one of the following users to the data use agreement:

• Data Custodian: Individual who will be responsible for ensuring that the environment in which the CMS data is stored complies all applicable CMS data security requirements, including the establishment and maintenance of security arrangements to prevent unauthorized use. Please note, CMS requires only one data custodian per data environment.

• Data Recipient: An individual under the oversight of the Data Custodian that will receive physical shipment or virtual download of CMS data.

Important Notes:

• All form fields are required.

• CMS does not require this form for updates to existing contact information (e.g., e-mail address, phone numbers), but only to add an individual who is not already on the DUA.

• CMS does not accept mailbox rental services (P.O. Box, UPS Store, etc.) for an address.

• CMS does not accept foreign addresses outside of the United States and its territories.

• CMS does not accept personal e-mail addresses (@yahoo, @gmail, @outlook, etc.). Your e-mail must be associated with your employer, organization, or university.

• All CMS data must physically remain within the boundaries of the United States and its territories.

Name: Phone: Ext.:

Organization:

Street Address:

City:

Email:

By signing this form, you are attesting to the terms and conditions defined in the original Data Use Agreement (DUA) documentation.

Signature:

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 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, Md. 21244-1850.

Form CMS-R-0235A (06/12)