Forms

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• 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 1-855-202-1058.
• Navigate PCP Change Request Form – Submit this form to alert CareSource to a change within your practice.
• 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.
• Navigate Provider Debarment Form – Use this form to provide attestation of provider information.

Member-Related Forms

• Navigate Interpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource members.
• Navigate Coordination of Healthcare Exchange of Information Form – Behavioral health providers should use this form when referring members to primary care and other health services to promote safe and effective coordination of care.
  • Navigate Coordination of Healthcare Exchange of Information FAQ
• Life Services Referral Form – 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

• Navigate 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).
• Navigate Synagis Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
• Medication-Assisted Treatment (Buprenorphine Products) Prior Authorization Form – Submit this form to request prior authorization to prescribe buprenorphine and buprenorphine-containing medications.
• 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.
• 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.
• Navigate Diabetes Testing Supplies Prior Authorization Form – Submit this form to request prior authorization to Diabetes Testing Supplies.

Medical and Other Prior Authorization

• Navigate 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

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

Appeals

• Navigate Provider Appeal Form – Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.
• 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.

Fraud, Waste and Abuse

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

Other 

• Navigate Aeroflow Breast Pump Order Form – Submit this form via fax to order a breast pump for your patient.