Forms

Below, you’ll find essential forms and documents providers need to best serve our members.

Note: You may need to download Adobe Acrobat Reader to open these files.

Contracting and Practice Changes

• 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 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.
• Navigate Provider Debarment Form – Use this form to provide attestation of provider information.
• Navigate Interpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource member.

Member-Related Forms

• Navigate PCP Change Request Form
• 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.

Medical Prior Authorization Forms

• Navigate 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.
• Nursing Facility Form – Submit this form to request prior authorization for a nursing facility admission
• 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.
• Navigate SUD 1115 Waiver Universal Prior Authorization Form – Submit the SUD 1115 Waiver Universal PA Form to request prior authorization for residential and partial hospitalization Substance Use Disorder (SUD) services.

Claims Forms

• ECHO Health Enrollment – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Overpayment Recovery Form – Providers may submit Recovery Requests via the Provider Portal.
• 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.
• Claim Refund Check Form – Mail your refund check, this form and any other required documentation to CareSource.
• Navigate Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
• 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.

Appeals Forms

• 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 – Submit this form to request an appeal on behalf of a member.
• 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.
• Navigate Provider Appeal Request Form – Submit this form to request an appeal for an authorization, post-service, contract or other issue.

Dental Forms

• 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.
• ADA Dental Claim Form Instructions – Follow the instructions to fill out the American Dental Association’s (ADA) dental claim form.
• Dental EFT Enrollment Authorization Agreement Form – Follow the instructions to enroll in Scion Dental’s EFT program.
• CareSource TMD Screening Examination Form – Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.

Fraud, Waste and Abuse Forms

• Fraud, Waste and Abuse Reporting Form – Submit this form to report suspected fraud, waste or abuse.

Prior Authorization Forms

• 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.