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

• Navigate Interpreter Service Request Form
  Submit this form to request interpretation services for an upcoming appointment for a CareSource member.
• 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 Debarment Form
  Use this form to provide attestation of provider information.
• Provider Maintenance Form (accessible via the provider portal)
  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

• 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.
• Navigate PCP Change Request Form
  Use this form to submit a PCP change request.
  

Medical Prior Authorization Forms

• Nursing Facility Form
  Submit this form to request prior authorization for a nursing facility admission.
  
• Navigate Ohio Association of Health Plans Universal Outpatient Behavioral Health Prior Authorization Form
  Submit this universal Ohio Association of Health Plans form to request prior authorization for outpatient behavioral health services.
• Navigate Ohio Urine Drug Screen Prior Authorization Form
  Submit this form to request prior authorization for urine drug screening for Ohio Medicaid patients with a substance use disorder.
• Navigate SUD 1115 Waiver Universal Prior Authorization Form
  Submit the SUD 1115 Waiver Universal PA Form to request prior authorization for residential and partial hospitalization Substance Use Disorder (SUD) services.

Claims Forms

• Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to CareSource.
  
• CMS 1500 Health Insurance Claim Form
  Waiver services providers who cannot log into the provider portal can use this form to submit a claim. You can access Instructions to complete the form and a list of valid service codes.
• ECHO Health Enrollment
  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.
  
• Navigate 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

• Navigate Appointment of Representation (AOR) Form
  Submit this form if you are not a physician or a physician representative.
  
• 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 Provider Appeal Request Form
  Submit this form to request an appeal for an authorization, post-service, contract or other issue.
  
• 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.

Dental Forms

• ADA Dental Claim Form Instructions
  Follow the instructions to fill out the American Dental Association’s (ADA) dental claim form.
  
• CareSource TMD Screening Examination Form
  Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.
• Dental EFT Enrollment Authorization Agreement Form
  Follow the instructions to enroll in Scion Dental’s EFT program.
• ODJFS Dental Services Prior Authorization Form
  Submit this form to the Ohio Department of Job and Family Services (ODJFS) to request prior authorization for dental services.

Fraud, Waste and Abuse Forms

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

Prior Authorization Form

• Navigate Utilization Management Prior Authorization Form
  Submit this form to request prior authorization from Utilization Management for medical services (such as inpatient admission or home health care), or for durable medical equipment.