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Addendum To Data Use Agreement (DUA) CMS-R-0235A - Official Federal Forms
| Addendum To Data Use Agreement (DUA) Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0734 ADDENDUM TO DATA USE AGREEMENT (DUA) Addendum to DUA for _________________________________________ . If this is an addendum to a previously approved DUA, insert the CMS assigned DUA number here: ___________________. The following individual(s) may/will have access to CMS data that is being requested for this agreement. Their signatures attest to their agreement to the terms of this Data Use Agreement: Name and Title of Individual (typed or printed) Task / Role of this individual in this project Street Address City Office Telephone (Include Area Code) Signature State ZIP Code E-Mail Address (If applicable) Date Company / Organization Name and Title of Individual (typed or printed) Task / Role of this individual in this project Street Address City Office Telephone (Include Area Code) Signature State ZIP Code E-Mail Address (If applicable) Date Company / Organization Name and Title of Individual (typed or printed) Task / Role of this individual in this project Street Address City Office Telephone (Include Area Code) Signature State ZIP Code E-Mail Address (If applicable) Date Company / Organization 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 30 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: Reports Clearance Officer, Baltimore, Maryland 21244-1850. Form CMS-R-0235A (11/05) EF 11/2005 American LegalNet, Inc. www.USCourtForms.com 1
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