Forms

Easily find the forms you need for your CareSource plan here.

Explanations of when and why you may need to use a form are also provided below. The instructions on each form will tell you where you need to return it, who to contact if you have questions and any next steps to take. Forms may be downloaded for printing.

• Navigate Appointment of Representative (AOR) Form
  Use this form when you want someone else to be able to receive information about your coverage or care and act on your behalf; for example, a provider, attorney, spouse or friend.
  
• External Review of a Drug Exception Request by Independent Review Entity
  Use this online form when CareSource denies your request for an exception to a drug listed on the CareSource Marketplace Drug Formulary, and you want to ask for an external review of the request.
• Navigate External Review Request Form
  Use this form if you received a Notice of Final Adverse Benefit Determination and you would like an independent review entity to review the decision.
• Fraud, Waste & Abuse Reporting Form
• HIPAA Authorization Form – Online
  Use this online form to grant CareSource permission to speak to another individual on your or your child’s behalf, and/or release health information to someone you name. Or download this Navigate hard-copy version and mail or fax the completed form to us. Please allow up to 30 days to process the hard-copy form.
• Navigate Member Appeal Request Form
  Use this form if you received a Notice of Adverse Benefit Determination and you would like CareSource to review the decision.
• Member Exception Request Form
  Use this online form to ask for an exception to a drug listed on the CareSource Marketplace Drug Formulary.
• Navigate Member Claim Form
  Use this form to request to be reimbursed if you paid for medical expenses that should have been covered under your CareSource benefits.
• Prescription Reimbursement Claim Form
  Use this form to request to be reimbursed if you paid for a prescription that should have been covered under your CareSource drug benefits.
• Tell Us
  Use this form when you would like to send us a question or request online.
• Navigate Transplant DONOR Travel Reimbursement Form
• Navigate Transplant RECIPIENT Travel Reimbursement Form
• Navigate Treating Physician Certification for Experimental/Investigational Adverse Benefit Determinations Form
  Use this form to certify that an experimental and/or investigational drug, device, procedure, or therapy is needed as part of an external review.
• Navigate Treating Physician Certification for Internal Appeal and/or External Review Form
  Use this form to certify that an expedited internal appeal and/or external review is necessary.