Caregiver Forms

These forms allow caregivers to work with CareSource on behalf of their loved ones.

Member Consent/HIPAA Authorization Form

• Gives permission for CareSource to speak with a caregiver about a member’s medical, payment or protected health information.
• A CareSource member or appointed representative may complete this form when applicable.

Appointment of Representative Form

An appointed representative is a relative, friend, advocate, provider or other person authorized to act on a member’s behalf in filing a grievance, coverage determination or appeal. Those not authorized under State law to act for the member will need to sign the form and mail it to the addresses below:

• For medical coverage: CareSource, P.O. Box 1947, Dayton, OH 45401-1947
• For prescription drug coverage: Express Scripts, c/o Medicare Clinical Appeals, P.O. Box 66588, St. Louis, MO 63166-6588

See other CareSource forms.