These forms allow caregivers to work with CareSource on behalf of their loved ones.
- Allows a member to decide if they want to share their health information with past, current, and future providers as well as with the Health Information Exchange(s).
- 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.
- 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.
CareSource® MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees.
CMS Approved 10/1/2018