Forms

Instructions are included on each form. It will tell you where to send it if it is not online. Questions? Call Member Services at 1-844-607-2829 (TTY: 711). We can send printed form copies to you.

Tell Us: Use this form to send us a question. You can also make a complaint, file an appeal, add a new address or phone number, or tell us if you have other insurance.

Member Consent/HIPAA Authorization Form: Share your health information with your providers or someone else. Or fill out this hard-copy to send to us:

CareSource Privacy Office

P.O. Box 8738

Dayton, OH 45401-8738 

Fraud, Waste and Abuse Reporting Form: Use this form if you think a member or provider is taking part in fraud, waste, or abuse.

Grievance and Appeals Form: Use this form if you have a complaint about a service or care you got from a provider. Or fill it out if you do not agree with a decision we made.

Member Claim Form: Ask to be reimbursed for services you paid for. You may get reimbursed if it should have been paid for by CareSource.

Member Exception Request: Use this form to ask for an exception for a medication not on the PDL.

Prescription Reimbursement Claim Form: Ask for a reimbursement for a prescription drug you paid for.