Forms

We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.

Administrative

• Critical Incident Report Form
  Use this form to submit a Critical Incident Report.
• Navigate Facility Change Request Form
  Use this form to submit a facility change request.

Contracting and Practice Changes Forms

• Navigate Coordination of Care and Release of Information Form
  Use this form to share patient care information with another provider. Please note the release of information clause.
• New Health Partner Contract Form
  Submit this form if you are interested in becoming a CareSource provider. Need help? Refer to the Navigate Becoming a Health Partner Step-by-Step Guide. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2122.
• Navigate Primary Care Provider (PCP) Change Request Form
  Use this form to submit a PCP change request.
• Provider Debarment Form (coming soon)
  Use this form to provide attestation of provider information.
• Provider Education Attestation Form (coming soon)
  Use this form to provide attestation of completing education requirements.
• Provider Maintenance Form (coming soon)
  Use the provider portal to alert CareSource to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation bar.

Medical Prior Authorization Forms

• Care Management Referral Form (coming soon)
  This form can be submitted using the Provider Portal.
• Coordination of Care and Release of Information Form (coming soon)
  Use this form to share patient care information with another provider. Please note the release of information clause at the end of page 2.
• Interpreter Service Request Form (coming soon)
  Submit this form to request interpretation services for an upcoming appointment for a CareSource member.
• Life Services Referral Form (coming soon)
  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.
• Navigate Medical Prior Authorization Form

Prior Authorization Requests

• Navigate Multi-Ingredient Compound Prior Authorization Form
• Navigate Pharmacy Prior Authorization Request Form
• Navigate Specialty Pharmacy Prior Authorization Form

Claims Forms

• Navigate Abortion, Hysterectomy, and Sterilization (AHS) Consent Forms Submission Instructions
• Navigate Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to CareSource.
• CMS 1500 Health Insurance Claim Form (coming soon)
  Waiver services providers who cannot log into the provider portal can use this form to submit a claim. You can access instructions (coming soon)to complete the form and a list of valid service codes.
• ECHO Health Enrollment (coming soon)
  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Itemized Bill Cover Sheet (coming soon)
  Submit this cover sheet and itemized statement for high dollar claims.
• Navigate Overpayment Recovery Form
  Providers may submit Recovery Requests via the provider portal.
• Navigate Provider Standard Claim Dispute Form
  Submit this form to dispute a standard claim. The best way to submit is via the provider portal. It can also be mailed to the address on the bottom of the form.

Appeals Forms

• • Navigate Consent for Provider to File an Appeal on Patient/Member's Behalf
    Submit this form to request an appeal on behalf of a member.
  • Navigate Provider Standard Appeal Request Form
    Submit this form to request an appeal for an authorization, post-service, contract or other issue.

Fraud, Waste and Abuse

• Fraud, Waste and Abuse Reporting Form (coming soon)
  Submit this form to report suspected fraud, waste or abuse.