Forms

Some forms must be completed online; others must be downloaded, printed and mailed or faxed back. If you have questions or need help with a form, please contact Member Services at 1-877-514-2442 (TTY: 711).

• Navigate Appointment of Representative (AOR) Form
  Use this form when you want someone else to be able to receive information about your coverage or care and act on your behalf, for example, a provider, attorney, spouse or friend.
• Fraud, Waste & Abuse Reporting Form
• HIPAA Authorization Form (Online Secure Form | Printable PDF)
  Use this form to grant CareSource permission to speak to another individual on your or your child’s behalf, and/or release health information to someone you name. Complete the form online or download the printable version and mail or fax the completed form to us. Please allow up to 30 days to process the printable form.
• Navigate Member Appeal Request Form
  Use this form if you received a Notice of Adverse Benefit Determination and you would like CareSource to review the decision.
• Drug Exception Request Form
  If you need a medicine that is not listed on the CareSource Marketplace Drug Formulary, use this online form to ask for an exception.
• External Review of a Drug Exception Request by IRE
  If CareSource denies your request for an exception to a drug listed on the CareSource Marketplace Drug Formulary, Use this online secure form to ask for an external review of the request by an Independent Review Entity.
• Member Claim Forms
  • Navigate Medical Reimbursement Claim Form
    If you paid for medical expenses that should have been covered under your CareSource plan, use this form to ask to be reimbursed.
  • Prescription Reimbursement Claim Form
    If you paid for a prescription that should have been covered under your CareSource drug benefits, use this form to ask to be reimbursed.
• Member Change Form (coming soon)
  Use this form when you need to make a change to an existing policy such as changing your address or name change, terming a dependent, or cancelling the entire policy.
• Tell Us Online Secure Form
  Use this form when you would like to send us a question or request online.
• Navigate Transplant DONOR Travel Reimbursement Form
  If you donate the gift of life as a live organ donor, use this form to ask for reimbursement for your eligible transplant donation related travel expenses.
• Navigate Transplant RECIPIENT Travel Reimbursement Form
  If you receive the gift of life through an organ transplant, use this form to ask for reimbursement for your eligible transplant related travel expenses.