Caregiver Forms

This form  lets caregivers to work with CareSource  for their loved ones. 

Member Consent/HIPAA Authorization Form

  •  Lets us to speak with a caregiver about a member’s medical, payment or protected health information. 
  • A CareSource member or appointed representative may  fill out this form.

Member Services: 1-855-202-0729 (TTY: 1-800-255-0056 or 711), Monday – Friday 7 a.m. – 7 p.m.