Forms

Below, you’ll find essential forms and documents providers need to best serve our members.

Note: You may need to download Adobe Acrobat Reader to open these files.

Contracting and Practice Changes

New Health Partner Contract Form – Submit this form if you are interested in becoming a CareSource provider. Need help? Refer to the Navigate 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 1-833-230-2176.
Navigate Provider Debarment Form – Use this form to provide attestation of provider information.
Provider Education Attestation Form – Use this form to provide attestation of completing education requirements.

Navigate Medical Prior Authorization Form – Submit this form to request prior authorization for a medical procedure.

ECHO Health Enrollment – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
Navigate Overpayment Recovery Form – Submit this form to offset overpaid claims against a future payment.
Claim Refund Check Form (coming soon) – Mail your refund check, this form and any other required documentation to CareSource.
Navigate Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
Navigate 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.

Navigate Waiver of Liability Form for Claim Appeals – Submit this form with all non-participating provider claims appeals. CMS requires this form or appeal request will be dismissed.
Navigate Consent for Provider to File an Appeal on Patient/Member's Behalf – Submit this form to request an appeal on behalf of a member.
Navigate Provider Appeal Request Form – Submit this form to request an authorization, post-service, contract or other issue.
Navigate Appointment of Representation (AOR) form – Submit this form if you are not a physician or a physician representative.

Navigate Fraud, Waste and Abuse Reporting Form – Submit this form to report suspected fraud, waste or abuse.