Caregiver Forms

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

Member Consent/HIPAA Authorization Form

  • A member can decide if they want to share their health information with past, current and future providers and the Health Information Exchange(s).
  • Gives 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

  • Names a relative, friend, advocate, doctor or anyone else to act as the member’s appointed representative.
  • Grants legal permission to act as the member’s appointed representative for an initial determination or decision, appeal or grievance.
  • CareSource members may complete this form and obtain the appointed representative’s signature when applicable.

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 1947, Dayton, OH 45401-1947
  • For prescription drug coverage: Express Scripts, c/o Medicare Clinical Appeals, PO Box 66588, St. Louis, MO 63166-6588

See other CareSource forms.