Forms

Listed below are all the forms you may need as a 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 Form
    An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in filing a grievance, coverage determination or appeal. Those not authorized under State law to act for you will need to sign this form and mail it to:
    For medical coverage:
    HAP CareSource
    P.O. BOX 1025
    Dayton, OH 45401
  • Coverage Determination Request Form online or Navigate hard copy
    If you believe you are entitled to payment or benefits on a certain Part D drug, you can request a coverage determination.
  • Coverage Redetermination Request Form online or Navigate hard copy 
    If you are not happy with the outcome of a coverage determination request, you can file an appeal.
  • Grievance/Appeal Form (coming soon)
    Use this form if you have a complaint about a service or care you got from a provider. You can also fill this out if you do not agree with a decision we made.
  • Navigate Member Consent HIPAA Authorization Form
    Use this form to give permission to share your health information with your providers and/or release health information to someone you name.
  • Navigate Member Claim Form
    Fill this out to ask to be reimbursed for services you paid for. You may get reimbursed if the services should have been paid for by us.
  • Navigate Part D Direct Member Reimbursement Form
    Use this form to request to be reimbursed if you paid for a prescription that should have been covered under your plan.
  • Navigate Prior Authorization Request Form
    Some services require approval before you can get them. Your provider can submit a request for a prior authorization using this form.
  • Tell Us
    Use this form when you would like to send us a question or request. You can also make a complaint, file an appeal, report a new address or PCP change, or tell us if you have other insurance.‌ We will get back with you within one business day.