Forms

NAME OF THE FORM

WHEN TO USE

Use this form when you would like to send us a question or request online.

2025 Enrollment Form (Updated 10/1/2024)   

2024 Enrollment Form (Updated 10/1/2023)

Use this form to enroll in a CareSource Dual Advantage plan.

Care Management Contact Form

Use this form to contact your Care Management representative for a personalized approach to your health care needs.

Use this form to request to be reimbursed if you paid for medical expenses that should have been covered under your CareSource Medicare Advantage benefits.

Prescription Reimbursement Claim Form (Updated 10/21/2019) 

Use this form to request to be reimbursed if you paid for a prescription that should have been covered under your CareSource Medicare Advantage drug benefits.

Member Consent/HIPAA Authorization Form – Online

Use this form to give your consent to share your health information with your providers and/or release health information to someone you name.

Or download this hard-copy version (Updated 7/27/2021) and mail or fax the completed form to us. Please allow up to 10 days to process the hard-copy form.

Coverage Determination Request Form online or hard copy (Updated 3/01/2021)

If you believe you are entitled to payment or benefits on a certain drug, you can request a coverage determination by completing this form.

Coverage Redetermination Request Form online or hard copy (Updated 3/01/2021

If you are unsatisfied with the outcome of a coverage determination request, you can file an appeal using the redetermination form.

Appointment of Representative Form

An appointed representative is a relative, friend, advocate, provider or other person authorized to act on your behalf in filing a grievance, coverage determination or appeal. Those not authorized under State law to act for you will need to sign this form and mail it to the addresses below:

• • For medical coverage: CareSource, P.O. Box 1947, Dayton, OH 45401-1947
  • For prescription drug coverage: Express Scripts, c/o Medicare Clinical Appeals, PO Box 66588, St. Louis, MO 63166-6588.

Prior Authorization Request Form (Updated 3/02/2021)

Some services require that your doctor or health care provider get approval from CareSource before you can get the service. Your provider can submit a request for a prior authorization using this form. A list of services that require Prior Authorization is available on the Plan Documents page.