Forms

New Health Partner Contract Form

Submit this form if you are interested in becoming a CareSource^® provider. 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 Debarment Form

Use this form to provide attestation of provider information.

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.

Care Management Referral Form

This form can be submitted using the Provider Portal.

Coordination of Care and Release of Information Form

Use this form to share patient care information with another provider. Please note the release of information clause at the end of page 2.

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.

 Care Provider (PCP) Change Request Form

Members may submit this form to request a change in PCP.

Medical Provider Administered Drugs Prior Authorization Form

Submit this form to request prior authorization to prescribe provider administered drugs covered and reimbursable by CareSource. Please see the Pharmacy page for more information.

Hyaluronic Acid Injections Prior Authorization Form

Submit this form to request prior authorization to prescribe Hyaluronic Acid Injections  covered and reimbursable by CareSource.

Synagis Prior Authorization Form

Submit this form to request prior authorization to prescribe Synagis covered and reimbursable by CareSource.

Ohio Department of Medicaid (ODM) Pharmacy Prior Authorization Forms 

Visit the ODM Prior Authorization (PA) Information page or the Single Pharmacy Benefit Manger (SPBM) website for prior authorization forms for prescription drugs and products covered through the SPBM, Gainwell Technologies.

Home Health Care Services Prior Authorization Form

Submit this form to request prior authorization for home health care services.

Medical Prior Authorization Form

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

Nursing Facility Form

Submit this form to request prior authorization for a nursing facility admission.

Ohio Association of Health Plans Universal Outpatient Behavioral Health Prior Authorization Form

Submit this universal Ohio Association of Health Plans form to request prior authorization for outpatient behavioral health services.

Ohio Urine Drug Screen Prior Authorization Form

Submit this form to request prior authorization for urine drug screening for Ohio Medicaid patients with a substance use disorder (SUD).

SUD 1115 Waiver Universal Prior Authorization Form

Submit the SUD 1115 Waiver Universal PA Form to request prior authorization for residential and partial hospitalization SUD services.

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.

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.

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

Consent for Provider to File an Appeal on Patient/Member’s Behalf

Submit this form to request an appeal on behalf of a member.

Provider Standard Appeal Request Form

Submit this form to request an appeal for an authorization, post-service, contract or other issue. This form can be submitted using the Provider Portal (preferred submission method).

Fraud, Waste and Abuse Reporting Form

Submit this form to report suspected fraud, waste or abuse.