Forms

plan. Listed below are all the forms you may need as a HAP CareSource MI Health Link 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.
• Navigate 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.
• Navigate Member Consent HIPAA Authorization Form – Use this form to give your permission to share your health information with your providers and/or release health information to someone you name. Mail or fax the completed form to us. Please allow up to 10 days to process the hard-copy form.
• 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 HAP CareSource MI Health Link plan.
• Navigate Coverage Determination Request Form – If you believe you are entitled to payment or benefits on a certain drug, you can request a coverage determination by completing this form.
• Navigate Coverage Redetermination Request Form – If you are unsatisfied with the outcome of a coverage determination request, you can file an appeal using the redetermination form.
• Navigate 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 the addresses below:
  • For medical coverage:
    • HAP CareSource
      P.O. Box 1947
      Dayton, OH 45401-1947
  • For prescription drug coverage:
    • Express Scripts
      c/o Medicare Clinical Appeals
      P.O. Box 66588
      St. Louis, MO 63166-6588.
• Navigate Prior Authorization Request Form – Some services require that your doctor or health care provider get approval from CareSource before you can get the service. Your provider can submit a request for a prior authorization using this form. A list of services that require Prior Authorization is available on the Plan Documents