Forms used to update the DUA Information

Use Agreement (DUA) Limited Data Set (LDS) Forms Research Identifiable Files (FIF) Forms (CMS-R-235)

Documents and Forms

Document Name Document Type
Form CMS-R-235 Forms used to update the DUA Information Form and Instruction
CMS-R-235 DUA Certificate of Disposition RIF COD_508.docx Form and Instruction
CMS-R-235 QE DUA Signature Addendum QE DUA Signature Addendum_.docx Form and Instruction
CMS-R-235 NDTR DUA Signature Addendum NDTR DUA Signature Addendum.docx Form and Instruction
CMS-R-235 Contractor DUA Signature Addendum Contractor DUA Signature Addendum_.docx Form and Instruction
RIF-COD REDLINE.pdf Track Change - RIF COD IC Document
RIF COD_JobAid.pdf RIF COD_JobAid IC Document
Contractor Signature Addendum_JobAid.pdf Contractor Signature Addendum_JobAid IC Document
QE Signature Addendum_JobAid.pdf QE Signature Addendum_JobAid IC Document
NDTR Signature Addendum_JobAid.pdf NDTR Signature Addendum_JobAid IC Document

Information Collection (IC) Details

IC Title:	Forms used to update the DUA Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235	DUA Certificate of Disposition	RIF COD_508.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	QE DUA Signature Addendum	QE DUA Signature Addendum_.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	NDTR DUA Signature Addendum	NDTR DUA Signature Addendum.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Contractor DUA Signature Addendum	Contractor DUA Signature Addendum_.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,800	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,800	-2,800	5,600
Annual IC Time Burden (Hours)	476	-476	952
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change - RIF COD	RIF-COD REDLINE.pdf	05/27/2025
RIF COD_JobAid	RIF COD_JobAid.pdf	05/28/2025
Contractor Signature Addendum_JobAid	Contractor Signature Addendum_JobAid.pdf	05/28/2025
QE Signature Addendum_JobAid	QE Signature Addendum_JobAid.pdf	05/28/2025
NDTR Signature Addendum_JobAid	NDTR Signature Addendum_JobAid.pdf	05/28/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.