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.
| NAME OF THE FORM | WHEN TO USE |
|---|---|
| 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. |
| 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. |
| Member Consent HIPAA Authorization Form (coming soon) | Use this form to give permission to share your health information with your providers and/or release health information to someone you name. |
| 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. |
| Medicare Part D Coverage Determination Request Form | If you believe you are entitled to payment or benefits on a certain Part D drug, you can request a coverage determination. |
| Medicare Part B Drug Organization Determination Request (coming soon) | 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. |
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 D Coverage Redetermination Request Form | If you are not happy with the outcome of a coverage determination request for a Part D drug, you can file an appeal. |
| 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:
|
| Prior Authorization Request Form | 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. |