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Update Your Information
- New Health Partner Contract Form – Submit this form if you are interested in becoming a CareSource® provider.
- New Provider Step-by-Step Guide to Become a CareSource Health Partner – Use this guide for instructions on becoming a CareSource participating provider.
- Organizational Provider Credentialing Application Form – Use this form to supply demographic, certification and billing information and submit the form along with your New Health Partner Contract Form.
- Provider Debarment Form – Use this form to provide attestation of provider information and submit it along with your New Health Partner Contract Form
- 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. If you are unable to access the Provider Portal, please contact your Health Partner Engagement Specialist for assistance.
- Rendering Provider List – Use this spreadsheet to list all provider information for rendering providers.
- W-9 Tax Form – Use this form to provide your Taxpayer Identification Number (TIN) and certification information. Please submit this form along with your New Health Partner Contract Form.
- Certificate of Preventive Services Form – Submit this form to indicate the preventive services the member received during the measure year.
- Coordination of Healthcare Exchange of Information Form – Use this form when referring members to behavioral health services to promote safe and effective coordination of care.
- HIPAA Consent Form – This form is used for members to consent to sharing health information with health care providers
- Indiana Health Coverage Programs (IHCP) Fast Track Notification Form – Any IHCP provider that assists an individual with a Fast Track prepayment and renders services prior to a final eligibility determination may complete this form to notify the appropriate managed cate entity (MCE) of a forthcoming request for retroactive prior authorization (PA).
- Interpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource member.
- 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.
- Medically Frail FAQs
- Member Related Forms
- Pre-Birth Selection Form – Submit this form to request primary medical provider (PMP) assignment for a member’s baby prior to birth.
- Substance Use Disorder Quality Improvement Project Case Management Referral Form – Submit this form to engage members admitted to the emergency department with substance use disorder (SUD) in case management.
Pharmacy Prior Authorization
Medical Prior Authorization
- 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.
Contracting and Practice Changes
- Provider Education Attestation Form – Use this form to provide attestation of completing education requirements.