Forms

We want you to easily find the forms you need. Explanations of when and why you may need to use a form are also listed. 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.

  • Appointment of Representative Form (coming soon)

    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:

    • For medical coverage: CareSource, P.O. Box 1947, Dayton, OH 45401-1947
    • For prescription drug coverage: Express Scripts, c/o Medicare Clinical Appeals, P.O. Box 66588, St. Louis, MO 63166-6588.
  • Grievance/Appeal Form
    Use this form when you have a complaint about service you have received or would like to dispute a decision that has been made.
  • Medicaid Covered Drug Prior Authorization Form (coming soon)
    If you believe you are entitled to payment or benefits on a certain Medicaid covered drug, you can request a prior authorization.
  • Medicare Part B Drug Organization Determination Request
    If you believe you are entitled to payment or benefits on a certain Part B drug, you can request an organization determination at www.EviCore.com.
  • Medicare Part D Coverage Determination Request Form (English | Spanish)
    If you believe you are entitled to payment or benefits on a certain Part D drug, you can request a coverage determination.
  • Medicare Part D Coverage Redetermination Request Form (Navigate English | Navigate Spanish)
  • Member Consent HIPAA Authorization Form 
    Use this form to give permission to share your health information with your providers and/or release health information to someone you name.
  • Navigate Part D Direct Member Reimbursement Form
    Use this form to request to be reimbursed if you paid for a prescription that should have been covered under your plan.
    If you are not happy with the outcome of a coverage determination request for a Part D drug, you can file an appeal.
  • Prior Authorization Request Form (coming soon)
    Some services require your provider get approval from CareSource before you can get the service. Your provider can submit a request for a prior authorization.
  • Tell Us
    Use this form when you would like to send us a question or request. We will get back with you within one business day.