Forms

New Health Partner Contract Form

Submit this form if you are interested in becoming a CareSource^® provider. Need help? Refer to the User’s Guide for Completing New Health Partner Contract Form. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2101.

PCP Change Request Form

Submit this form to alert CareSource to a change within your practice.

Provider Debarment Form

Use this form to provide attestation of provider information.

Provider Maintenance Form

Use the Provider Portal to alert CareSource to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation.

Coordination of Healthcare Exchange of Information FAQ

Interpreter Service Request Form

Submit this form to request interpretation services for an upcoming appointment for a CareSource member.

Life Services Referral Form

CareSource Life Services^® is a program that provides non-medical support that can include assistance with housing, food insecurity and employment. Use this form to refer a patient to this program.

Navigate Pharmacy Prior Authorization Request Form

Submit this form to request prior authorization to prescribe pharmacy medications under the pharmacy benefit.

Navigate Specialty Pharmacy Prior Authorization Request Form

Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the CareSource member’s Preferred Drug List (PDL).

Synagis Prior Authorization Form

Submit this form to request prior authorization to prescribe Synagis.

Medical Prior Authorization Request Form

Submit this form to request prior authorization for a medical or behavioral health service.

Provider Attestation Regarding IEP/IFSP for Outpatient Therapy Services

Submit this form along with a prior authorization request for Children’s Intervention School (CIS) services.

Provider Education Attestation Form

Use this form to provide attestation of completing education requirements.

Claim Refund Check Form

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.

Consent for Provider to File an Appeal on Patient/Member’s Behalf

Submit this form to request an appeal on behalf of a member.

Provider Appeal Form

Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.

Fraud, Waste and Abuse Reporting Form

Submit this form to report suspected fraud, waste or abuse.

Aereflow Breast Pump Order Form

Submit this form via fax to order a breast pump for your patient.