CMS Data Disclosures and Data Use Agreements (DUAs): Forms

Guidance for the forms associated with Data Use Agreements.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: May 12, 2020

Data Use Agreement Forms

Below is a listing of forms associated with CMS Data Use Agreements (DUAs). Additional forms may be required for researchers requesting specific Research Identifiable Files (RIFs). Researchers requesting RIF data should contact the Research Data Assistance Center (ResDAC) to obtain specific forms associated with the data they are requesting.

Data Use Agreement Signature Form – Form CMS-R-0235a (PDF) - Use this form to establish or update the Data Custodian on Contractor or LDS DUAs For RIF DUAs, contact the Research Data Assistance Center (ResDAC).
Certificate of Disposition – Form 10252 (PDF) – Use this form to request closure of a DUA.
LDS Pricing and Request Order Form (ZIP) - Use this form to request new data files.
LDS Re-Use Form (ZIP) - Use this form to request to use data in your possession for a new project.

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