Beneficiary Claim Form DisposeRx® Request Form: Get a free DisposeRx packet to help you dispose of unused or expired medications. Fraud, Waste and Abuse Reporting Form: Use this form if...

Provider Attestation Form – Submit this form to attest to practice competency prior to working with CareSource. CCVS Provider Authorization and Release Form – Submit this form to authorize release...

...Summary of Formulary Changes Effective April 1, 2024 03/01/2024 Summary of PDL Changes Effective March 15, 2024 02/15/2023 Summary of PDL Changes Effective January 01, 2024 12/01/2023 Summary of Formulary...

Form 1099-MISC is an Internal Revenue Service (IRS) tax form that shows payments that CareSource issued to a provider, vendor or independent contractor. Form 1099-MISC is mailed to recipients by...

...Change Form. Once complete, email the form to providernetwork@hap.org with the subject line: Provider Change Form. In the body of the email, be sure to include: Type 1 NPI Type...

...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...

...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...

...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...

...View COVID-19 Information Drug Formulary Drug Formulary Look up medications for your patient’s plan. Learn More Forms Forms Find forms for contracting, authorization, claim submission and more. View Forms Provider...