Form CMS-10340 CSSC Operations Submitter Authorization Form

CSSC OPERATIONS
SUBMITTER AUTHORIZATION FORM

OMB No. 0938-1152
(Expires: TBD)

Instructions: The following information must be completed by an authorized representative of the contract. This form
should not be completed by a PBM or Third Party submitter. The completed form may be submitted online, printed and
faxed to 1-803-935-0171, or scanned and sent via email to [email protected]. 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
Encounter Data (Medicare A, B, DME)
Prescription Drug Event
Risk Adjustment
Medicare-Medicaid
Encounter Data
Medicaid (A, B, DME, Dental)
National Council Prescription Drug (NCPDP)
Prescription Drug Event
Risk Adjustment

Third Party or
PBM Name

Third Party or PBM
Submitter ID (if available)

Receive
Reports

Submitter Only
Submitter Only
Submitter Only
Submitter Only
Submitter Only
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
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1152. The time required to complete this information collection
is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
CMS-10340(12/14)
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