Forms

Chris, do your magic on this with the Adobe Acrobat Download section....beeee-uuuu-tified!

CareSource has many materials for providers. These are listed below. Please click on the link to open the item. Each item will open as a PDF. You need Adobe Acrobat Reader to open these files. If you do not have Adobe Acrobat Reader, you can download it here.

Medicaid

Claims

• Provider Claim Research Request 
• Provider Claim Appeal Request
• Provider Profile Form

Medical

• Acknowledgement of Receipt of Hysterectomy
• Informed Consent Form for Sterilization
• Institute for Health Care Studies EPSDT Toolkit and Forms
• List of Services That Require Prior Authorization 
• Maternal Support Services Risk Screening Tool 
• Prior Authorization Request Form
• Referral and Prior Authorization Required
• Synagis Prior Authorization Request Form

Pharmacy

• Non-Formulary Drug Prior Authorization Form
• Preferred Drug List

Other

• CareSource Corporate Compliance Plan
• Fraud, Waste, and Abuse Reporting Form
• 2008 Synagis Webinar - 09/24/08
• Fair Hearing Policy

Medicare

Pharmacy

• 2009 Prescription Drugs Prior Authorization Form
• 2010 Prescription Drugs Prior Authorization Form
• 2009 Prescription Drugs Appeal Policy
• 2010 Prescription Drugs Appeal Policy
• 2009 Prescription Drugs Redetermination Policy
• 2010 Prescription Drugs Redetermination Policy
• 2009 Prescription Drugs Exceptions to Formulary Policy
• 2010 Prescription Drugs Exceptions to Formulary Policy

Medical and other

• 2009 Appeal Form
• 2010 Appeal Form
• 2009 CMS Appointment of Representative Form
• 2010 CMS Appointment of Representative Form
• 2009 Medical Prior Authorization Form
• 2010 Medical Prior Authorization Form