Forms

We want you to easily find the forms you need for your CareSource plan.  Listed below are all the forms you may need as a CareSource member.

Explanations of when and why you may need to use a form are also provided below. Look for instructions on each form. The instructions will tell you where you need to return each form, who to contact if you have questions and any next steps to take. Forms may be downloaded for printing.

For more information on Georgia Pathways to Coverage:

https://dch.georgia.gov/georgiapathways

You can find CareSource forms here:

• gateway.ga.gov – Use this link for the DCH Enrollment Broker site.
• Tell Us – Use this form when you would like to send us a question or request online.
• Grievance/Appeal Form – Use this form when you have a complaint about service you have received or would like to dispute a decision that has been made.
• Medicaid Eligibility Redeterminations
• Pharmacy Preferred Drug List
• Pharmacy Conditions for Coverage and Utilization Limits
• Prescription Reimbursement Claim Form
• What’s New?
• Member Claim Form (coming soon)
• Fraud, Waste and Abuse Reporting Form – Use this form if you think a health partner or a CareSource member is committing fraud, waste or abuse. To find out more, visit the Fraud, Waste, & Abuse page.
• Member Consent/HIPAA Authorization Form– Use this form to give your consent to share your health information with your providers and/or release health information to someone you name. Or, download this hard-copy version and mail or fax the completed form to us. Please allow up to 30 days to process the hard-copy form.
• IRS 1095B Information
• IRS 1095B Form
• Letter from Georgia Department of Community Health
• More Information
• Frequently Asked Questions about the 1095B Tax Form

Member Services: 1-855-202-0729 (TTY: 1-800-255-0056 or 711), Monday – Friday 7 a.m. – 7 p.m.