Forms

Navigate 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.

Navigate PCP Change Request Form

Use this form to submit a PCP change request.

Nursing Facility Form

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

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

Navigate 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.

Submit the SUD 1115 Waiver Universal PA Form to request prior authorization for residential and partial hospitalization Substance Use Disorder (SUD) services.

Claim Refund Check Form

Mail your refund check, this form and any other required documentation to CareSource.

CMS 1500 Health Insurance Claim Form

Waiver services providers who cannot log into the provider portal can use this form to submit a claim. You can access Instructions to complete the form and a list of valid service codes.

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.

Navigate Appointment of Representation (AOR) Form

Submit this form if you are not a physician or a physician representative.

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

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

Navigate Provider Appeal Request Form

Submit this form to request an appeal for an authorization, post-service, contract or other issue.

Navigate Waiver of Liability Form for Claim Appeals

Submit this form with all non-participating provider claims appeals. CMS requires this form or appeal request will be dismissed.

ADA Dental Claim Form Instructions

Follow the instructions to fill out the American Dental Association’s (ADA) dental claim form.

CareSource TMD Screening Examination Form

Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.

Dental EFT Enrollment Authorization Agreement Form

Follow the instructions to enroll in Scion Dental’s EFT program.

strong>ODJFS Dental Services Prior Authorization Form

Submit this form to the Ohio Department of Job and Family Services (ODJFS) to request prior authorization for dental services.

Fraud, Waste and Abuse Reporting Form

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

Navigate Utilization Management Prior Authorization Form

Submit this form to request prior authorization from Utilization Management for medical services (such as inpatient admission or home health care), or for durable medical equipment.