This form allows caregivers to work with CareSource on behalf of their loved ones.
Member Consent/HIPAA Authorization Form
- Grants 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.
Member Services: 1-855-202-0729 (TTY: 1-800-255-0056 or 711), Monday – Friday 7 a.m. – 7 p.m.