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.
• Navigate Grievance/Appeal Form – When you have a complaint about a service or would like to dispute a decision.
• Navigate 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 Navigate hard-copy version. Please allow up to 30 days to process.
• Navigate Authorized Representative Designation Form  – You can use this form to name your representative.
• Navigate Pre-Birth Selection Form – You can use this form to tell us who your provider is before you give birth.
• Navigate 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.