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. Forms may be downloaded for print.
- Tell Us – Use this form when you would like to send us a question or request online.
- Grievance and Appeal Form – Use this 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 repayment for a prescription drug you paid for.
- Fraud, Waste and Abuse Reporting Form – Use this 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 – Use this form to give your consent to share your health information. You can also fill out a hard-copy version. This form may take up to 30 days to process.
- Authorized Representative Designation Form – Use this form to name someone who can speak on your behalf.
- Pre-Birth Selection Form – Use this form to tell us who your provider is before you give birth.
- Member Claim Form – Use this form to submit a claim to us for services.
- Member Exception Request for Non-Formulary Medication Form – Use this form to send us a request for a drug not listed on your Preferred Drug List.
Member Services: 1-844-607-2829 (TTY: 1-844-743-3333 or 711), Monday through Friday, 7 a.m. CT/8 a.m. ET to 7 p.m. CT/8 p.m. ET.