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 Navigate Becoming a Health Partner Step-by-Step Guide. 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 bar.

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.