Forms

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 Clinical/Claim Appeal Request Form - NEW! May 2010
• Claims Recovery Request Form - NEW! April 2010
• Provider Profile Form

Dental

• Orthodontic Evaluation and Pre-Determination Form
• Orthodontist Confirmation Form
• Dental Claims Form
• ODJFS Prior Authorization for Dental Services Form 

Medical

• ODJFS Abortion Certification Form
• Breast Pump Prescription Form
• ODJFS Acknowledgement of Hysterectomy Information -Updated: July 2009
• ODJFS Consent to Sterilization Form  - Updated: July 2009
• Case Management Referral
• Prior Authorization Request Form - Medical/Specialty Drug Request Form - NEW! August 2010
• Online Prior Authorization Request - Medical/Specialty Drug Requests Only
• Synagis Prior Authorization Request Form
• Medical Necessity Appeal Request Form
• PCP Member Fax Form
• Prior Authorization Form for Home Health Care Services
• Prenatal Risk Assessment Form

Medicare

Pharmacy

• 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 - NEW! August 2010

Other

• Confidential Fraud, Waste and Abuse Reporting Form
• Non-Preferred Drug Form