Forms
We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.
Note: You may need to download Adobe Acrobat Reader to open these files.
Contracting and Practice Changes 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. | Submit this form to alert CareSource to a change within your practice. |
Use this form to provide attestation of provider information. | 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. |
Member-Related Forms
Interpreter Service Request Form Submit this form to request interpretation services for an upcoming appointment for a CareSource member. | 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. |
Pharmacy Prior Authorization Forms
Diabetes Testing Supplies Prior Authorization Form Submit this form to request prior authorization to Diabetes Testing Supplies. | Extended Release Opioid Prior Authorization Form Submit this form to request prior authorization to prescribe extended release opioids that exceed daily, dose, or quantity limits. | Immediate Release Opioid Prior Authorization Form Submit this form to request prior authorization to prescribe immediate release opioids that exceed daily, dose, or quantity limits. | Medication-Assisted Treatment (Buprenorphine Products) Prior Authorization Form Submit this form to request prior authorization to prescribe buprenorphine and buprenorphine-containing medications. |
Pharmacy Prior Authorization Request Form Submit this form to request prior authorization to prescribe pharmacy medications under the pharmacy benefit. | Specialty Pharmacy Prior Authorization Request Form or Universal 17P Authorization Form Submit one of these forms to request prior authorization to prescribe specialty pharmacy medications, as outlined in the CareSource member’s Preferred Drug List (PDL). | Synagis Prior Authorization Form Submit this form to request prior authorization to prescribe Synagis. |
Medical and Other Prior Authorization Forms
Medical Prior Authorization Request Form Submit this form to request prior authorization for a medical or behavioral health service. | Provider Attestation Regarding IEP/IFSP for Outpatient Therapy Services Submit this form along with a prior authorization request for Children’s Intervention School (CIS) services. | Provider Education Attestation Form Use this form to provide attestation of completing education requirements. |
Claims Forms
Mail your refund check, this form and any other required documentation to CareSource | Submit this form to enroll with ECHO Health, our electronic funds transfer partner. |
Submit this cover sheet and itemized statement for high dollar claims. | Submit this form to offset overpaid claims against a future payment. |
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
Consent for Provider to File an Appeal on Patient/Member’s Behalf Submit this form to request an appeal on behalf of a member. | Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision. |
Fraud, Waste and Abuse Form
Fraud, Waste and Abuse Reporting Form Submit this form to report suspected fraud, waste or abuse. |
Miscellaneous Forms
Aereflow Breast Pump Order Form Submit this form via fax to order a breast pump for your patient. |