Forms

Coordination of Healthcare Exchange of Information Form

Use this form when referring members to behavioral health services to promote safe and effective coordination of care.

HIPAA Consent Form

This form is used for members to consent to sharing health information with health care providers

Organizational Provider Credentialing Application Form

Use this form to supply demographic, certification and billing information and submit the form along with your New Health Partner Contract Form.

Provider Debarment Form 

Use this form to provide attestation of provider information and submit it along with your New Health Partner Contract Form.

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. If you are unable to access the Provider Portal, please contact your Health Partner Engagement Specialist for assistance.

Rendering Provider List

Use this spreadsheet to list all provider information for rendering providers.

W-9 Tax Form

Use this form to provide your Taxpayer Identification Number (TIN) and certification information. Please submit this form along with your New Health Partner Contract Form.

Coordination of Healthcare Exchange of Information Form

Use this form when referring members to behavioral health services to promote safe and effective coordination of care.

HIPAA Consent Form

This form is used for members to consent to sharing health information with health care providers

Interpreter Service Request Form

Submit this form to request interpretation services for an upcoming appointment for a CareSource member.

Life Services Referral Form 

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. 

Medically Frail FAQs

Pre-Birth Selection Form

Submit this form to request primary medical provider (PMP) assignment for a member’s baby prior to birth.

Substance Use Disorder Quality Improvement Project Case Management Referral Form

Submit this form to engage members admitted to the emergency department with substance use disorder (SUD) in case management.

Submit this form to request prior authorization for a medical procedure.

Submit this form to enroll with ECHO Health, our electronic funds transfer partner.

Use this form to provide attestation of completing education requirements.