Form CMS-R-0235MA: Addendum to the Medicaid Agency Data Use Agreement (DUA)

Form CMS-R-0235MA is the Addendum to the Medicaid Agency Data Use Agreement (DUA) from the Centers for Medicare & Medicaid Services. The CMS page titles it the Addendum to the Medicaid State Agency Data Use Agreement. The form lists the individuals who may or will have access to the CMS data being requested for Title II ADA/Olmstead activities, and says their signatures attest to their agreement to the terms of the Data Use Agreement.

The top of the form names the DUA the addendum is for and, if it adds to a previously approved DUA, the CMS assigned DUA number. Each individual block asks for a name and title, the person's task or role in the project, organization, address, office telephone and email, with signature lines for the individual, a CMS Representative and, if applicable, a CMS Project Officer.

A note says some existing DUAs lack the Item #4 language on facilitating State compliance with the Americans with Disabilities Act, and that for those a custodian is added on this form. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Form CMS-R-0235MA: Addendum to the Medicaid Agency Data Use Agreement (DUA), as printed by CMS

What's on Form CMS-R-0235MA

DUA identification

Addendum to DUA for (a blank for the DUA), and the CMS assigned DUA number if this adds to a previously approved DUA.

Item #4 note

A note that some existing DUAs do not contain the Item #4 language on facilitating State compliance with the Americans with Disabilities Act, and that a custodian is added below for those.

Individual details

Name and title (typed or printed), task or role in the project, company or organization, street address, city, state, ZIP code, office telephone and email if applicable.

Signatures

Signature of the individual, of the CMS Representative and, if applicable, of the CMS Project Officer, each with a date.

One page with a header and two identical blocks, one per individual.

How to fill out Form CMS-R-0235MA

1
Name the DUA
Enter what the addendum is for and, if it adds to a previously approved DUA, the CMS assigned DUA number.
2
Check the Item #4 language
The form says that if the existing DUA lacks the Item #4 language on Americans with Disabilities Act compliance, a custodian is added below.
3
Enter each individual
Fill in one block per individual with name and title, role, organization, address, office phone and email.
4
Collect signatures
Each individual signs and dates, followed by a CMS Representative and, if applicable, a CMS Project Officer.

Why fill Form CMS-R-0235MA on indox

You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.

Fill the form right in your browser, no software to install
Free to fill and free to download, with no account
The official blank straight from the CMS, not a copy someone retyped
Works on a phone, tablet or computer

What the form and the CMS page say

Where it goes

Neither the form nor the CMS page gives a submission address. The CMS address in the Paperwork Reduction Act notice is for comments on the time estimate.

OMB number

The form prints OMB No. 0938-0734. The CMS page lists an OMB expiration date of December 31, 2014.

Time to complete

The form estimates an average of 30 minutes per response, including reviewing instructions and gathering the data needed.

Who uses Form CMS-R-0235MA?

Medicaid agency DUA holders
The addendum is for an existing or requested Medicaid agency Data Use Agreement, named at the top of the form, with the CMS assigned DUA number if one was already approved.
People with data access
The individuals who may or will have access to the CMS data requested for Title II ADA/Olmstead activities. The form says their signatures attest to their agreement to the DUA terms.
Custodians
For DUAs whose Item #4 does not include the language on facilitating State compliance with the Americans with Disabilities Act, the form says a custodian is added.
CMS signers
Each block has a signature line for a CMS Representative and, if applicable, a CMS Project Officer, each with a date.

The form is an addendum to a Medicaid agency Data Use Agreement with CMS. It names these people.

Official sources and the blank

Official CMS form page
The agency’s own page for Form CMS-R-0235MA.
Blank PDF
The official blank form, to print or fill by hand.

Do it all with indox

View all 94 tools

Questions about Form CMS-R-0235MA

What is Form CMS-R-0235MA?

It is the Addendum to the Medicaid Agency Data Use Agreement (DUA). It lists individuals who may or will have access to CMS data requested for Title II ADA/Olmstead activities.

What do the signatures on Form CMS-R-0235MA mean?

The form says the individuals' signatures attest to their agreement to the terms of the Data Use Agreement.

Does Form CMS-R-0235MA need a DUA number?

The form asks for the CMS assigned DUA number if the addendum adds to a previously approved DUA.

When is a custodian added?

The form says some existing DUAs lack the Item #4 language on facilitating State compliance with the Americans with Disabilities Act, and for those a custodian is added on the form.

Who signs besides the individual?

Each block has lines for a CMS Representative and, if applicable, a CMS Project Officer, each with a date.

Form CMS-R-0235MA: Addendum to the Medicaid Agency Data Use Agreement (DUA)