Forms

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Contracting and Practice Changes Forms

• New Health Partner Contract Form
  Submit this form if you are interested in becoming a CareSource^® provider. This form can also be used to change your tax ID number, as well as add products. Need help? Refer to the User’s Guide for Completing New Health Partner Contract Form. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2101
• Provider Education Attestation Form
  Use this form to provide attestation of completing education requirements.
• 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.

Member-Related Forms

• Navigate PCP Change Request Form
• Navigate Coordination of Care and Release of Information Form

Pharmacy Prior Authorization Forms

• Navigate Compound Prior Authorization Form
  Submit this form to request prior authorization to prescribe compounds.
• Navigate Pharmacy Prior Authorization Form
  Submit this form to request prior authorization to prescribe certain medications, as outlined in the Formulary.
• Navigate Specialty Pharmacy Prior Authorization Form
  Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the Formulary.
• Navigate Synagis Prior Authorization Form
  Submit this form to request prior authorization to prescribe Synagis.

Medical Prior Authorization Form

• Navigate Medical Prior Authorization Form
  Submit this form to request prior authorization for a medical procedure.

Claims Forms

• Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to CareSource.
• ECHO Health Enrollment
  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Navigate Itemized Bill Cover Sheet
  Submit this cover sheet and itemized statement for high dollar claims.
• Overpayment Recovery Form
  Providers may submit Recovery Requests via the Provider Portal.
• Navigate Provider Standard Claim Dispute Form
  Submit this form to dispute a standard claim. The best way to submit is via the Provider Portal. It can also be mailed to the address on the bottom of the form.

Disputes & Appeals Forms

• Navigate Appointment of Representative to File an Appeal on Patient/Member's Behalf
  Submit this form to request an appeal on behalf of a member.
• Navigate Expedited Appeal Form
  If you feel a standard appeal time frame will harm your patient, please complete and mail this form to the address provided.
• Navigate Standard Appeal Form
  Submit this form to request an appeal for an authorization, post-service, contract or other issue.

Fraud, Waste and Abuse Form

• Navigate Fraud, Waste and Abuse Reporting Form
  Submit this form to report suspected fraud, waste or abuse.