Caregiver Forms

These forms allow caregivers to work with CareSource on behalf of their loved ones.

Member Consent/HIPAA Authorization Form

  • Grants permission for CareSource to speak with a caregiver about a member’s medical, payment or protected health information. 
  • A CareSource member or appointed representative may complete this form when applicable.

Appointment of Representative Form

An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on a member’s behalf in filing a grievance, coverage determination or appeal. Those not authorized under State law to act for the member will need to sign this form and mail it to the addresses below:

  • For medical coverage: CareSource, P.O. Box 1432, Dayton, OH 45401-1432
  • For prescription drug coverage: CareSource Part D Appeals, c/o CVS Caremark, P.O. Box 52136, Phoenix, AZ 85072-2136