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.
- 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.
- 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.
- Prescription Reimbursement Claim Form
- 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.
- Payroll Deduction – Use this form to set up a payroll deduction to pay your Healthy Indiana Plan (HIP) POWER account contribution (PAC). Please note, this form lets CareSource coordinate with your employer. It does not automatically enroll you in Employer Payroll Deduction.
- Authorized Representative Designation Form
- Pre-Birth Selection Form