Forms
We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.
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 1-855-202-1058.
Submit this form to alert CareSource to a change within your practice.
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.
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.
Pharmacy Prior Authorization Request Form
Submit this form to request prior authorization to prescribe pharmacy medications under the pharmacy benefit.
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.
Mail your refund check, this form and any other required documentation to CareSource
Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
Submit this cover sheet and itemized statement for high dollar claims.
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.
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.