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.

Contracting and Practice Changes

  • Coordination of Care and Release of Information Form (coming soon)
    Use this form to share patient care information with another provider. Please note the release of information clause.

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

Medical Prior Authorization

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

  • Nursing Facility Form (coming soon)
    Submit this form to request prior authorization for a nursing facility admission.

  • Ohio Urine Drug Screen Prior Authorization Form (coming soon)
    Submit this form to request prior authorization for urine drug screening for Ohio Medicaid patients with a substance use disorder.

  • SUD 1115 Waiver Universal Prior Authorization Form (coming soon)
    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 (coming soon)
    Mail your refund check, this form and any other required documentation to CareSource.

  • CMS 1500 Health Insurance Claim Form (coming soon)
    Waiver services providers who cannot log into the provider portal can use this form to submit a claim. You can access instructions (coming soon) to complete the form and a list of valid service codes.

  • ECHO Health Enrollment (coming soon)
    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 (coming soon)
    Providers may submit Recovery Requests via the provider portal.

  • Provider Standard Claim Dispute Form (coming soon)
    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

  • Appointment of Representation (AOR) Form (coming soon)
    Submit this form if you are not a physician or a physician representative.

  • Consent for Provider to File an Appeal on Patient/Member’s Behalf (coming soon)
    Submit this form to request an appeal on behalf of a member.

  • Provider Appeal Request Form (coming soon)
    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.

Fraud, Waste and Abuse

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

Prior Authorization

  • Utilization Management Prior Authorization Form (coming soon)
    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.