CMS-10340 CSSC Operation Submitter Authorization Form (hardcopy)

CSSC OPERATIONS
SUBMITTER AUTHORIZATION FORM
Instructions: The following information must be completed by an authorized representative from the plan. This form
should be not completed by a PBM or Third Party submitter. The completed form may be printed and faxed to 1-803935-0171 or scanned and sent via email to [email protected] for processing. Please note that all required
forms (i.e. EDI Agreement and Submitter Application) must be received by all entities involved in order to complete setup.

This form authorizes the following entities to submit data and receive reports on behalf of
____________________________ for the following contract(s) effective ____________:
(Organization name)

(Date)

Please provide the PBM/Third Party Submitter information authorized to submit for each Submission Type.
Submission Type

Third Party or
PBM Name

Third Party or PBM
Submitter ID (if available)

Receive
Reports

Encounter Data (Medicare A, B, DME)
Prescription Drug Event
Risk Adjustment
Medicare-Medicaid

Submitter Only

Medicaid (A, B, DME, Dental)

Submitter Only

National Council Prescription Drug (NCPDP)

Submitter Only

Encounter Data

Submitter Only

Submitter Only

Prescription Drug Event
Risk Adjustment

Submitter Only

I am authorized to complete the Submitter Authorization Form on behalf of the indicated party and agree to the
instructions as outlined above.
____________________________________________
Name

____________________________
Date

_____________________________________________
Title

_________________________________________
Email Address

(____) _____________________________
Phone

Submitter Authorization Form
CSSC Operations – AG-570
2300 Springdale Drive – Bldg. One
Camden, SC 29020-1728
Phone: (877) 534-2772