Forms

We want you to easily find the forms you need for your HAP CareSource plan. Listed below are all the forms you may need as a HAP CareSource member.

Explanations of when and why you may need to use a form are also provided below. Look for instructions on each form. The instructions will tell you where you need to return each form, who to contact if you have questions and any next steps to take. Forms may be downloaded for printing.

• Navigate Appointment of Representative Form
  Use this form when you want someone else to be able to receive information about your coverage or care and act on your behalf; for example, a provider, attorney, spouse or friend.
• External Review Request Form
  Use this form if you received a Notice of Final Adverse Benefit Determination and you would like an independent review entity to review the decision.
• Fraud, Waste & Abuse Reporting Form
• HIPAA Authorization Form – Online
  Use this online form to grant HAP CareSource permission to speak to another individual on your or your child’s behalf, and/or release health information to someone you name. Or download this Navigate hard-copy version and mail or fax the completed form to us. Please allow up to 30 days to process the hard-copy form.
• Navigate Internal Appeal Request Form
  Use this form if you received a Notice of Adverse Benefit Determination and you would like HAP CareSource to review the decision.
• Navigate Member Claim Form
  Use this form to request to be reimbursed if you paid for medical expenses that should have been covered under your HAP CareSource benefits.
• Member Exception Request Form
  Use this Member Exception Request Form to ask for an exception to a drug listed on the HAP CareSource Marketplace Drug Formulary.
• Prescription Reimbursement Claim Form
  Use this form to request to be reimbursed if you paid for a prescription that should have been covered under your HAP CareSource drug benefits.
• Tell Us
  Use this form when you would like to send us a question or request online.
• Navigate Transplant DONOR Travel Reimbursement Form
• Navigate Transplant RECIPIENT Travel Reimbursement Form