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

• New Health Partner Contract Form
  Submit this form if you are interested in becoming a CareSource^® provider. Need help? Refer to the Becoming a Health Partner Step-by-Step Guide. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-800-488-0134.
• Provider Debarment Form
  Use this form to provide attestation of provider information.
• Provider Education Attestation Form
  Use this form to provide attestation of completing education requirements.
• 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

• 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.
• Navigate Special Supplemental Benefits for the Chronically Ill (SSBCI) Provider Attestation Form
  Submit this form to confirm your patient has been diagnosed with one or more qualifying conditions and meets the CMS criteria for receiving SSBCI.
• 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.
• 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.
• Community Behavioral Health Rehabilitative Services Form
  Ohio Department of Medicaid approved form to request authorization for community behavioral health rehabilitative services.
• Substance Use Disorder Services Authorization Request
  Ohio Department of Medicaid approved form to request authorization for Substance Use Disorder Services Authorization Request for ASAM Levels of Care.

Claims Forms

• Navigate Claim Refund Check Form
  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.
• Navigate Overpayment Recovery Form
  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 Representative (AOR) Form
  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
  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.