Forms

We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.

Note: You may need to download Adobe Acrobat Reader to open these files.

Contracting and Practice Changes Forms

• Provider Debarment Form
  Use this form to provide attestation of provider information.
• 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 bar.

Member-Related Forms

• 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 Form

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

Claims Forms

• Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to CareSource.
• ECHO Health Enrollment Form
  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Navigate Itemized Bill Cover Sheet
  Submit this cover sheet and itemized statement for high dollar claims.
• Overpayment Recovery Form
  Providers may submit Recovery Requests via the Provider Portal.
• Provider Standard Claim Dispute Form
  Submit this form to dispute a standard claim. The best way to submit is via the Provider Portal. It can also be mailed to the address on the bottom of the form.

Appeals Forms

• Appointment of Representation (AOR) Form
  Submit this form if you are not a physician or a physician representative.
• Expedited Appeal Form
  If you feel a standard appeal time frame will harm your patient, please complete and mail this form to the address provided.
• Provider Appeal Request Form
  Submit this form to request an appeal for an authorization, post-service, contract or other issue.
• 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.

Fraud, Waste and Abuse Form

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