Existing DUA number
The number of the data use agreement being updated, at the top right of the form.
CMS-R-0235U
Data Use Agreement (DUA)- Update to Existing DUA
- Agency
- CMS
- Revision
- 06/20
- Fillable fields
- 38
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-R-0235U: Data Use Agreement (DUA), Update to Existing DUA
Form CMS-R-0235U is the Data Use Agreement, Update to Existing Data Use Agreement, from the Centers for Medicare & Medicaid Services (CMS). It carries the heading Agreement for Use of Centers for Medicare & Medicaid Services (CMS) Data and asks for the number of the existing DUA at the top. It lists additional CMS data files being requested under that agreement.
The form says the agreement is needed as part of the review of a data request to ensure compliance with the requirements of the Privacy Act, and that it is completed prior to the release or use of specified data files. It has five numbered items: the requestor organization, the study or project and any CMS contract number, a table of additional files and years, the requesting individual's attestation and signature, and the CMS representative's attestation and signature.
Three lines at the bottom are for a CMS System Manager or Business Owner to concur or nonconcur. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-R-0235U
Items 1 and 2: Organization and project
The requestor organization, the name of the study or project, and the CMS contract number if applicable.
Item 3: Additional data files
A table of six lines for each additional CMS data file requested, the years, and the system of record to be completed by CMS staff.
Item 4: Requesting individual
The attestation for the user, with the requesting individual's typed or printed name, signature and date.
Item 5 and system sign-offs
The CMS representative's attestation, name, title, signature and date, then three lines for a CMS System Manager or Business Owner with signature, date, system name and Concur or Nonconcur.
The form fits on one page.
How to fill out Form CMS-R-0235U
- 1
Enter the existing DUA number
Write the number of the data use agreement being updated in the Existing DUA # box.
- 2
Name the organization and project
Fill in the requestor organization and the name of the study or project, and add the CMS contract number if applicable.
- 3
List the additional files
Enter each additional CMS data file and its years in item 3. The System of Record column is left for CMS staff.
- 4
Sign item 4
The requesting individual types or prints their name, signs and dates item 4.
- 5
Leave the CMS sections
Item 5 is for the CMS representative, and the sign-off lines below it are for CMS System Managers or Business Owners.
Why fill Form CMS-R-0235U 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 says
Why it is needed
The form says the agreement is needed as part of the review of a data request to ensure compliance with the requirements of the Privacy Act, and is completed prior to the release or use of specified data files.
Terms
Item 4 binds the user to the terms of the existing agreement. The form does not restate those terms.
Where it goes
The form does not print a submission address or a fee.
OMB number
The form shows Form Approved, OMB No. 0938-0734. The CMS page lists an OMB expiration date of 2023-06-30 and a revision date of 2020-06-11.
Related forms
CMS-R-0235L
Data Use Agreement (DUA)- Limited Data Sets
50 fields, 6 pages
CMS-R-0235A
Addendum to Data Use Agreement (DUA)
16 fields, 1 page
CMS-R-0235M
Medicaid Agency Data Use Agreement
45 fields, 6 pages
CMS-R-0235MA
Addendum to the Medicaid State Agency Data Use Agreement
26 fields, 1 page
CMS-R-0235MC
Compliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server
10 fields, 1 page
Who uses Form CMS-R-0235U?
The form updates a data use agreement that is already in place between CMS and a requesting organization.
Official sources and the blank
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Questions about Form CMS-R-0235U
What is Form CMS-R-0235U?
It is the Data Use Agreement, Update to Existing Data Use Agreement. It lists additional CMS data files being requested under a data use agreement that is already in place.
Is an existing DUA needed for Form CMS-R-0235U?
The form is titled Update to Existing Data Use Agreement and asks for the existing DUA number at the top.
Who fills in the System of Record column?
The form marks the System of Record column in item 3 as to be completed by CMS Staff.
Who signs Form CMS-R-0235U?
The requesting individual signs item 4, the CMS representative signs item 5, and up to three CMS System Managers or Business Owners sign and mark Concur or Nonconcur.
Which terms apply to the added files?
In item 4 the signer agrees, on behalf of the user, to the terms of the existing agreement and all the terms specified in it.
How many files can be listed?
Item 3 has six lines, each with a file, its years and a system of record.