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Certificate Of Data Destruction For Data Acquired CMS-10252 - Official Federal Forms
| Certificate Of Data Destruction For Data Acquired 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. 0938-1046 INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF DATA DESTRUCTION FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES This certificate is to be completed and submitted to CMS to certify the destruction of all CMS data covered by the listed Data Use Agreement (DUA). This includes any copies made of the files, any derivative or subsets of the files, and any manipulated files. The requestor may not keep any copies, derivative or manipulated files--all files must be destroyed. CMS will close the listed DUA upon receipt and review of this certificate. Directions for the completion of the certificate follow: n Complete the Requestor and Custodian's Organization and Contact information as listed in the DUA. n Provide the DUA number. Provide the Project/Study Name as listed on the DUA. Provide the CMS Project Officer, if applicable. Please list all data files and years covered by the DUA. A signature is required on this certification. The signature should be the requestor or Custodian listed on the DUA. If the DUA is for a CMS Contract/Demonstration, the CMS Project Officer must also sign the certificate. n n n n Please submit this certificate to: Director, Division of Privacy Compliance Division of Privacy Compliance Mailstop: N2-04-27 7500 Security Blvd. Baltimore, MD 21244 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 0938-1046. 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, Maryland 21244-1850. Form CMS-10252 (12/07) 1 American LegalNet, Inc. www.FormsWorkflow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 7500 Security boulevard baltimore, Maryland 21244-1850 CERTIFICATE OF DATA DESTRUCTION FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES REqUESTOR ORgANIzATION DATA USE AgREEMENT (DUA) NO. REqUESTOR CONTACT NAME PHONE NO. REqUESTOR ADDRESS CUSTODIAN ORgANIzATION CUSTODIAN CONTACT NAME CUSTODIAN ADDRESS PHONE NO. PROjECT/STUDy NAME CMS PROjECT OFFICER (if applicable) CMS Data Files Destroyed: Files Years By signing this Certification of Data Destruction, I confirm that the data acquired under DUA # been completely destroyed and no copies have been kept. REqUESTOR OR CUSTODIAN PRINTED NAME SIgNATURE DATE have CMS PROjECT OFFICER (if applicable) PRINTED NAME SIgNATURE DATE Form CMS-10252 (12/07) 2 American LegalNet, Inc. www.FormsWorkflow.com
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