CMS-10340 CSSC Operation Submitter Application (hardcopy)

CSSC OPERATION
SUBMITTER APPLICATION
Directions: Please complete each section of the application. By completing the application, you are
requesting the assignment of a Submitter ID Number for the submission of data to CMS.

Entity Type
Data Submission Type

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Contract
Third Party Submitter
Encounter Data
Medicare-Medicaid Data (MMP)
Prescription Drug Event (PDE)
Risk Adjustment Data

Organization Name
Contract Number
Address
Address 2
City, State, Zip
Fax Number
Operations Contact Representative
Name
Contact Number
Email
Technical Contact Representative
Name
Contact Number
Email
Connection Type

 FTP – Lease Line; Dial-up Modem
 NDM/Connect:Direct
 Gentran/TIBCO (MFT) – (used by Contract Submitters Only)

For Contract Submitters Only: Please list additional contracts to be linked to the assigned
Submitter ID.