The CMS-R-0235ST form, officially termed a Data Use Agreement, is a crucial document facilitated by the Department of Health and Human Services' Centers for Medicare & Medicaid Services (CMS). It establishes a formal arrangement between CMS and individual state entities regarding the use of specific CMS data that contains individual-specific information. This contract is designed to safeguard the integrity, security, and confidentiality of information within CMS's Privacy Act System of Records by outlining the conditions under which CMS data will be disclosed to and used by the states. It emphasizes that the CMS retains all ownership rights to the data, limiting its use solely to purposes outlined within the agreement, such as identifying Medicare individuals potentially eligible for State Buy-In programs or supporting the development of risk adjustment factors essential for fiscal planning. Besides stipulating the data's intended use, this agreement mandates the establishment of rigorous administrative, technical, and physical safeguards to protect data confidentiality and prevent unauthorized access. Additionally, it contains provisions for the periodic destruction or return of data files, asserts the prohibition of data misuse, and details the legal implications of unauthorized data disclosure. By undersigning the agreement, state agencies not only agree to abide by these stringent conditions but also acknowledge the potential criminal and administrative penalties for non-compliance. This agreement underscores a collaborative effort to utilize sensitive CMS data responsibly, ensuring that it serves its intended purpose without compromising individual privacy.
| Question | Answer |
|---|---|
| Form Name | Form Cms R 0235St |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | CMS R 0235ST cms data use agreement form |