Get Data Use Agreement (dua) Certificate Of Disposition (cod) For Data Acquired

This guide provides a comprehensive overview of how to accurately complete the DATA USE AGREEMENT (DUA) CERTIFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED. By following these simple steps, users will ensure proper documentation for data destruction or continued use under the guidelines set by the Centers for Medicare & Medicaid Services.

Follow the steps to fill out the form successfully.

1. Click ‘Get Form’ button to retrieve the DUA Certificate of Disposition and open it for completion.
2. In item #1, enter the name of the requester’s organization. Ensure the name is accurate as it will be used for verification.
3. In item #2, provide the specific DUA number associated with the data being disposed of. This number ensures the correct record is matched.
4. In item #3, check only one box that applies regarding the disposition of the DUA. The options include: a) all files approved for reuse; b) some files approved; c) no files received; or d) all files destroyed. If applicable, attach supporting documentation.
5. In item #4, read the certification statement carefully. By signing, you confirm that all data corresponding to the selected DUA has been disposed of correctly. Ensure all details in this declaration are accurate.
6. In item #5, print the name of the individual who is signing the form. This should be the person responsible for data handling.
7. In item #6, provide the phone number of the individual signing the form to facilitate any follow-up.
8. In item #7, enter the date on which the form is signed. This date is crucial for record-keeping.
9. In item #8, if necessary, provide an email address for the signing individual for any required follow-up.
10. In items #9a and 9b, you may optionally provide an alternate point of contact’s name, phone number, and email address to assist with inquiries.
11. In item #10, ensure the signature is completed by the individual listed in item #6. If the form allows, utilize the entire box for a digital signature.
12. Once the form is completed, save your changes. Depending on your needs, you can then download, print, or share the form as required. If digitally signed, attach the form to an email for submission. If not, sign, scan, and attach it to an email to send to DataUseAgreement@cms.hhs.gov.

Complete your forms accurately and efficiently online to ensure compliance with CMS guidelines.