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 1-833-230-2101.
• 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.
• Provider Education Attestation Form – Use this form to provide attestation of completing education requirements.

Member-Related Forms

• • Navigate PCP Change Request Form – Members may submit this form to request a change in primary care provider (PCP).

• • 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.

  • Life Services Referral Form – CareSource Life Services^® is a program that provides non-medical support that can include assistance with housing, food insecurity and employment. Use this form to refer a patient to this program.

Pharmacy Prior Authorization

• Navigate Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe certain medications, as outlined in the CareSource Formulary. 
• Hepatitis C Treatment Prior Authorization Form – Submit this form to request prior authorization for hepatitis C treatment.
• Navigate Specialty Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the Formulary.
• Navigate Synagis Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
• Navigate Medication-Assisted Treatment (Buprenorphine Products) Prior Authorization Form – Submit this form to request prior authorization to prescribe buprenorphine and buprenorphine-containing medications.
• Navigate Compound Prior Authorization Form – Submit this form to request prior authorization to prescribe compounds.

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.
• Navigate Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.

Disputes & Appeals

• Navigate Provider Dispute & Appeal Claim Form – Submit this form to request an appeal for an authorization, post-service, contract or other issue.
• Navigate Appointment of Representative to File an Appeal on Patient/Member's Behalf – Submit this form to request an appeal on behalf of a member.

Fraud, Waste and Abuse

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