Forms
Listed below are all the forms you may need as a CareSource member.
We also tell you when and why you may need each form below. Forms may be downloaded for printing.
- Tell Us – When you would like to send us a question or request online.
- Grievance/Appeal Form – When you have a complaint about a service or would like to dispute a decision.
- Prescription Reimbursement Claim Form – Use this form to ask for reimbursement for a prescription drug you paid for.
- Fraud, Waste and Abuse Reporting Form – When you think a health partner or a CareSource member is committing fraud, waste or abuse. Visit Fraud, Waste, & Abuse.
- Member Consent/HIPAA Authorization Form – Give your consent to share your health information with your providers and/or to someone you name. Or, fill out this hard-copy version. Please allow up to 30 days to process.
- Authorized Representative Designation Form – You can use this form to name your representative.
- Pre-Birth Selection Form – You can use this form to tell us who your provider is before you give birth.
- Member Claim Form – You can use this form to submit a claim to us for services.
Member Services: 1-844-607-2829 (TTY: 1-800-743-3333 or 711), 8 a.m. to 8 p.m., Monday – Friday Eastern Time.