Forms
Instructions are included on each form. They will tell you where you need to return it if it is not an online form. The form will also tell you who to call if you have questions. Call Member Services at 1-800-488-0134 (TTY: 711) to get a printed copy sent to you.
Tell Us
Use this form to send us a question. You can also make a complaint, file an appeal, report a new address or PCP change or tell us if you have other insurance.
Member Claim Form
Use this form to request a reimbursement if you paid for services that should have been paid by CareSource.
Member Consent/HIPAA Authorization Form
Share your health information with your providers or someone else. Or, you can fill out this hard-copy version (
English |
Spanish) to send to us:
CareSource Privacy Office
P.O. Box 8738
Dayton, OH 45401-8738
Fraud Waste and Abuse Reporting Form
Use this form if you think that a member, provider, or pharmacy is taking part in fraud, waste or abuse.
Grievances and Appeals Form
Use this form if you have a complaint about service you got or do not agree with a decision we made.
Member Claim Form
Fill this out to ask to be reimbursed for services you paid for. You may get reimbursed if the services should have been paid for by CareSource.
Authorized Representative Form
Use this hard-copy form to choose someone to act on your behalf when filing a grievance or appeal. We also have
instructions to help you fill out the form:
CareSource Member Appeals
P.O. Box 1947
Dayton, OH 45401-1947