Updated DUA Addendum Form

CMS has simplified the Addendum form used to process contact changes.

The new form includes:

• Definitions for Requestor, Custodian, and Subcontracting/Collaborating Organization
• Drop-down menus, where appropriate
• A space for Data Extract System (DESY) users to add their user ID

To view the new form, please open the attachment or visit https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS-R-0235A.pdf.

For information on requesting contact changes, see https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/Data-Disclosures-Data-Agreements/DUA_-_Contact_Changes.html.