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...

...out the form online. Print the form. (coming soon) Interpreter Service Request Form Tell Us (coming soon): Use this form when you would like to send us a question. You...

...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...

...be sure to attach your W-9 form when you submit this online form. Overpayment Recovery Form (Coming Soon) Submit this form to offset overpaid claims against a future payment. Payment...

...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...

...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 number NPI number Need help?...

...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...

...authorized representative must complete the Appointment of Representative form or the Internal Appeal Request form. Return the completed form to us along with your grievance, appeal, or request for an...