CMS-R-235 RIF Extenstion Request Form

RESEARCH IDENTIFIABLE FILE (RIF) AND LIMITED DATA SET (LDS) DATA USE AGREEMENT: EXTENSION REQUEST

4. If you answered “No” on #2, (a) provide information on why you haven’t publicly disseminated findings from your research in the past year and (b) describe your plans to publish findings within the next year

ATTESTATIONS

1. We are still using this data as originally requested for our Project/Study.

2. In accordance with the terms and conditions of the DUA, we understand that the data for this DUA may not be used in any form, or for any additional work, outside the scope of this DUA without the expressed written consent of CMS.

3. I have reviewed the contact information on the DUA and submitted necessary updates.

4. We request a one (1) year [or less, if applicable] extension for the DUA number listed above.

Signature Date

2