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.
- Appointment of Representative (AOR) Form
- Tell Us – Use this form when you would like to send us a question or request online.
- Member Claim Form – Use this form to request to be reimbursed if you paid for medical expenses that should have been covered under your CareSource benefits.
- Prescription Reimbursement Claim Form – Use this form to request to be reimbursed if you paid for a prescription that should have been covered under your CareSource drug benefits.
- HIPAA Authorization Form – Online – Use this online form to grant CareSource permission to speak to another individual on your or your child’s behalf, 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.
- Member Appeal Request Form
- Member Exception Request Form – Use this online form to ask for an exception to a drug listed on the CareSource Marketplace Drug Formulary.
- Internal Appeal Request Form – Use this form if you received a Notice of Adverse Benefit Determination and you would like CareSource to review the decision.
- External Review Request Form – Use this form if you received a Notice of Final Adverse Benefit Determination and you would like an independent review entity to review the decision.
- Treating Physician Certification for Experimental/Investigational Adverse Benefit Determinations Form – Use this form to certify that an experimental and/or investigational drug, device, procedure, or therapy is needed as part of an external review.
- Treating Physician Certification for Internal Appeal and/or External Review Form – Use this form to certify that an expedited internal appeal and/or external review is necessary.
- Appointment of Representative Form – Use this form when you want someone else to be able to receive information about your coverage or care and act on your behalf; for example, a provider, attorney, spouse or friend.
- Transplant DONOR Travel Reimbursement Form
- Transplant RECIPIENT Travel Reimbursement Form
- Fraud, Waste & Abuse Reporting Form