Physician-Information (Medicare Self-Referral Disclosure Protocol) {CMS-10328}

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0734 ADDENDUM TO THE MEDICAID AGENCY DATA USE AGREEMENT (DUA) Addendum to DUA for _________________________. If this is an addendum to a previously approved DUA, insert the CMS assigned DUA number here: __________. The following individual(s) may/will have access to the CMS data that is being requested for Title II ADA/Olmstead activities. Their signatures attest to their agreement to the terms of this Data User Agreement: Note: Some existing DUAs do not contain the following language under Item #6: %22To facilitate State compliance with the requirements of the Americans with Disabilities Act.%22 For these DUAs, a custodian must be added below. Name and Title of Individual Title/Component Company/Organization Street Address City Telephone (Include Area Code) Signature Name and Title of Individual Title/Component Company/Organization Street Address City Telephone (Include Area Code) Signature Name and Title of Individual Title/Component Company/Organization Street Address City Telephone (Include Area Code) Signature Form CMS-R-0235MA (01/06) EF 02/2006 (Typed or Printed) Mail Stop State ZIP Code E-Mail Address (If applicable) Date (Typed or Printed) Mail Stop State ZIP Code E-Mail Address (If applicable) Date (Typed or Printed) Mail Stop State ZIP Code E-Mail Address (If applicable) Date American LegalNet, Inc. www.USCourtForms.com