CSSC Submitter Authorization Form

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CSSC OPERATIONS
SUBMITTER AUTHORIZATION FORM

OMB No. 0938-1152
Expires 03/31/2025

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 printed and mailed, 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 Advantage A, B,
DME, Dental)

Third Party or
PBM Name

Third Party or PBM
Submitter ID (if available)

Receive Reports
Submitter Only

Prescription Drug Event

Risk Adjustment
Medicare-Medicaid
Encounter Data
Medicaid (A, B, DME, Dental)
National Council Prescription Drug (NCPDP)

Submitter Only
Submitter Only
Submitter Only
Submitter Only

Prescription Drug Event

Risk Adjustment

Form CMS-10340 (03/2025)

Submitter Only

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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 10 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.
Form CMS-10340 (03/2025)

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