Forms

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Contracting and Practice Changes

• New Health Partner Contract Form – Submit this form if you are interested in becoming a CareSource^® provider. Need help? Refer to the User’s Guide for Completing New Health Partner Contract Form. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2176.
• Provider Maintenance Form – Use the Provider Portal to alert CareSource to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation.
• Navigate Provider Debarment Form – Use this form to provide attestation of provider information.
• Provider Education Attestation Form – Use this form to provide attestation of completing education requirements.

Member-Related Forms

• • Navigate PCP Change Request Form
• Navigate Coordination of Care and Release of Information Form – Use this form to share patient care information with another provider. Please note the release of information clause at the end of page 2.

Medical Prior Authorization

• Navigate Medical Prior Authorization Form – Submit this form to request prior authorization for a medical procedure.

Claims

• ECHO Health Enrollment – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Overpayment Recovery Form – Providers may submit Recovery Requests via the Provider Portal.
• Claim Refund Check Form – Mail your refund check, this form and any other required documentation to CareSource.
• Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.

Appeals

• Navigate Waiver of Liability Form for Claim Appeals – Submit this form with all non-participating provider claims appeals. CMS requires this form or appeal request will be dismissed.
• Provider Appeal Request Form – Submit this form to request an appeal for an authorization, post-service, contract or other issue.
• Navigate Consent for Provider to File an Appeal on Patient/Member's Behalf – Submit this form to request an appeal on behalf of a member.
• Navigate Appointment of Representation (AOR) form – Submit this form if you are not a physician or a physician representative.

Fraud, Waste and Abuse

• Navigate Fraud, Waste and Abuse Reporting Form – Submit this form to report suspected fraud, waste or abuse.