Forms

We want you to easily find the forms you need for your CareSource plan. Listed below are all the forms you may need as a CareSource member.

Explanations of when and why you may need to use a form are also provided below. Look for instructions on each form. The instructions will tell you where you need to return each form, who to contact if you have questions and any next steps to take. Forms may be downloaded for printing.

Tell Us – Use this form when you would like to send us a question or request online.

Enrollment Form – Use this form to enroll in a CareSource Medicare Advantage plan.

Member Claim Form – Use this form to request to be reimbursed if you paid for medical expenses that should have been covered under your CareSource Medicare Advantage benefits.

Prescription Reimbursement Claim Form – Use this form to request to be reimbursed if you paid for a prescription that should have been covered under your CareSource Medicare Advantage drug benefits.

Member Consent/HIPAA Authorization Form – Online – Use this form to give your consent to share your health information with your providers and/or release health information to someone you name. Or download this hard-copy version and mail or fax the completed form to us. Please allow up to 10 days to process the hard-copy form.

Coverage Determination Request Form online or hard copy – If you believe you are entitled to payment or benefits on a certain drug, you can request a coverage determination by completing this form.

Coverage Redetermination Request Form online or hard copy – If you are unsatisfied with the outcome of a coverage determination request, you can file an appeal using the redetermination form.

Appointment of Representative Form – An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in filing a grievance, coverage determination or appeal. Those not authorized under State law to act for you 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

Prior Authorization Request Form – Some services require that your doctor or health care provider get approval from CareSource before you can get the service. Your provider can submit a request for a prior authorization using this form. A list of services that require Prior Authorization is available on the Plan Documents page.

You must use the in-network providers except in emergency or urgent care situations. If you obtain routine care from out-of-network-providers, neither Medicare nor CareSource will be responsible for the costs, unless specifically authorized by CareSource. You must use in-network pharmacies to access the prescription drug benefit, except under non-routine circumstances when you cannot reasonably use an in-network pharmacy.

CareSource is an HMO with a Medicare contract. Enrollment in CareSource Advantage® Zero Premium (HMO), CareSource Advantage® (HMO) and CareSource Advantage Plus® (HMO) depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.


Y0119_OHMA-M-0251
Updated 10/1/2018
CMS Accepted 9/25/2018