Forms
Below, you’ll find essential forms and documents providers need to best serve our members.
Note: You may need to download Adobe Acrobat Reader to open these files.
- New Health Partner Contract Form
Submit this form if you are interested in becoming a CareSource provider. Need help? Refer to the Step-by-Step Join Our Network Guide. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2176. -
Provider Debarment Form
Use this form to provide attestation of provider information. - Provider Education Attestation Form
Use this form to provide attestation of completing education requirements.
- New Health Partner Contract Form
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Medical Prior Authorization Form
Submit this form to request prior authorization for a medical procedure.
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Medical Prior Authorization Form
- Claim Refund Check Form (coming soon)
Mail your refund check, this form and any other required documentation to CareSource. - ECHO Health Enrollment
Submit this form to enroll with ECHO Health, our electronic funds transfer partner. -
Itemized Bill Cover Sheet
Submit this cover sheet and itemized statement for high dollar claims. -
Overpayment Recovery Form
Submit this form to offset overpaid claims against a future payment. -
Provider Standard Claim Dispute Form
Submit this form to dispute a standard claim. The best way to submit is via the Provider Portal. It can also be mailed to the address on the bottom of the form.
- Claim Refund Check Form (coming soon)
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Appointment of Representation (AOR) form
Submit this form if you are not a physician or a physician representative. -
Consent for Provider to File an Appeal on Patient/Member's Behalf
Submit this form to request an appeal on behalf of a member. -
Expedited Appeal Form
If you feel a standard appeal time frame will harm your patient, please complete and mail this form to the address provided. -
Provider Appeal Request Form
Submit this form to request an authorization, post-service, contract or other issue. -
Waiver of Liability Form for Claim Appeals
Submit this form with all non-participating provider claims appeals. CMS requires this form or appeal request will be dismissed.
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Appointment of Representation (AOR) form
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Fraud, Waste and Abuse Reporting Form
Submit this form to report suspected fraud, waste or abuse.
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Fraud, Waste and Abuse Reporting Form