Forms

We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.

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Contracting and Practice Changes

• New Health Partner Contract Form (coming soon)
  Submit this form if you are interested in becoming a HAP 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 (coming soon). 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 (coming soon)
  Use this form to provide attestation of completing education requirements.

• Provider Maintenance Form (coming soon)
  Use the Provider Portal to alert HAP CareSource to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation.

Member-Related Forms

• Navigate Member Exception Request for Non-Formulary Medication
• Coordination of Care and Release of Information Form (coming soon)
• Primary Care Provider (PCP) Change Request Form (coming soon)

Pharmacy Prior Authorization

• Navigate Multi-Ingredient Compound Prior Authorization Form
• Navigate Pharmacy Facility Change Request Form
• Navigate Pharmacy Prior Auth Request Provider Form
• Navigate Specialty Pharmacy Prior Auth Provider Form

Please Note: Prior authorization requests for medications administered under the medical benefit can be submitted electronically via the HAP CareSource Provider Portal. Pharmacy benefit requests may be submitted via the CoverMyMeds or SureScripts prior authorization portals. Note: All oncology medication treatment regimen requests must be submitted and reviewed through the EVITI Connect Portal.

Medical Prior Authorization

• Medical Prior Authorization Form (coming soon)
  Submit this form to request prior authorization for a medical procedure.

Claims

• Navigate Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to HAP CareSource.
• ECHO Health Enrollment (coming soon)
  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.
• Navigate Overpayment Recovery Form
  Providers may submit Recovery Requests via the Provider Portal.

Disputes & Appeals

• Appointment of Representative to File an Appeal on Patient/Member’s Behalf (coming soon)
  Submit this form to request an appeal on behalf of a member.
• Standard Appeal Form (coming soon)
  Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.

Fraud, Waste and Abuse

• Fraud, Waste and Abuse Reporting Form (coming soon)
  Submit this form to report suspected fraud, waste or abuse.