Caregiver Forms

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

Member Consent/HIPAA Authorization Form

  • 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.

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.