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.

Member-Related Forms

• • NavigatePCP Change Request Form – Members may submit this form to request a change in primary care provider (PCP).
  • Life Services Provider Referral Form – Submit this form to refer a CareSource member to the CareSource Life Services program.
  • NavigateCoordination 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

• NavigatePharmacy 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.
• NavigateSpecialty Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the Formulary.
• NavigateSynagis Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
• NavigateMedication-Assisted Treatment (Buprenorphine Products) Prior Authorization Form – Submit this form to request prior authorization to prescribe buprenorphine and buprenorphine-containing medications.
• NavigateCompound Prior Authorization Form – Submit this form to request prior authorization to prescribe compounds.
• NavigateHyaluronic Acid Injections Prior Authorization Form – Submit this form to request prior authorization to prescribe Hyaluronic Acid Injections.

Medical Prior Authorization

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

Disputes & Appeals

• NavigateProvider Dispute & Appeal Claim Form – Submit this form to request an appeal for an authorization, post-service, contract or other issue.
• NavigateAppointment 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.