...Authorization Request Form Specialty Pharmacy Prior Authorization Form Spinal Muscular Atrophy (SMA) Prior Authorization Provider Form T Testosterone Prior Auth Form Request Form Topical Agent Prior Authorization Request Form Tzield...

...You can also fill out a hard-copy version. This form may take up to 30 days to process. Authorized Representative Designation Form – Use this form to name someone who...

...the Non-Participating Provider Profile Form. CareSource is unable to process claims without this information. Please be sure to attach your W-9 form when you submit this online form. In addition...

...Representative form or the Internal Appeal Request form. Return the completed form to us along with your grievance, appeal, or request for an external review. These forms are available online...

...for that appeal and must be signed by the member. Please note: You can use the Internal Appeal Request form and the Appointment of Representative form to request the appeal...

...information about becoming a participating provider, please submit the following information when completing the New Health Partner Contract Form. Your W-9 tax form Name Specialty CAQH ID number Tax ID...

...Member Appeals P.O. Box 1947 Dayton, OH 45401 Toll Free: 937-487-0629 (for Expedited Review) Fax: 937-487-0629 Expedited Fax: 937-531-2398 You may also use the secure online form on our Forms...

...complete this form when applicable. Appointment of Representative Form An appointed representative is a relative, friend, advocate, provider or other person authorized to act on a member’s behalf in filing...

...The following is a list of available Prior Authorizations Forms: ABA Prior Authorization Form CES Waiver Prior Authorization Form Community Based/Behavioral Health Outpatient Prior Authorization Form EIDT/ADDT and ST/PT/OT Prior...

The comprehensive formulary is a list of all drugs covered under your CareSource Medicare Advantage plan. The formulary consists of more than 3,000 medications. Additionally, CareSource provides monthly formulary updates...