PRS Contract and Contact Verification Form

OMB No. 0938-1152

(Expires: TBD)

PRS Contract and Contact Verification Form

The following contract(s) are scheduled to receive a Payment Reconciliation Summary (PRS) report and/or Exclusion Report for <Variable Field: Payment Reconciliation Year will appear here> and are assigned to PRS Receiver ID: <Variable Field: Receiver ID will appear here>

Please confirm both the contract(s) and PRS contact information are correct by completing the Contract Assignment and Contact on File sections of the form outlined below. PRS sign-on credentials will not be sent until the verification form and all required documentation (if applicable) is received from your organization. To ensure timely receipt of the PRS sign-on credentials and instructions, verification must be completed and submitted to CSSC by <Variable Field: Deadline Date will appear here>.

In the event you have questions, please contact CSSC Operations at 1-877-534-2772 or by email at [email protected].

< Variable Field: A list of all PRS Contracts will appear here>

Name: < Variable Field: PRS Contact Name on file will appear here>

Email: < Variable Field: PRS Contact Email on file will appear here>

Phone Number: < Variable Field: PRS Contact Phone Number on file will appear here>

In the event the PRS contact information has changed, please click on the following link and provide the new contact information. New Contact Information.

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 5 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( / )

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