CareSource

Indiana Non-participating Provider Profile

Please complete this form for the provider listed on the attached claim; CareSource is unable to process the claim without this information. Please note that this document is for claims purposes only, and does not guarantee claims payment.

Please Note: Submissions are processed during business hours Monday through Friday from 8:00 a.m. to 4:30 p.m. Eastern Time (ET). Submissions received outside of business hours will be processed during the next business day.


1) Primary Practice

2) Secondary Practice

NOTE: PLEASE ATTACH A CURRENT W-9 FORM FOR THE TAX IDENTIFICATION NUMBER LISTED ON THIS FORM.

Selecting a new attachment replaces the current one.


November 2024
IN-EXCP-66
Provider Operations
P.O. Box 4135
Dayton, OH 45401-4135
Phone: 1-844-607-2829 Fax: 1-937-531-3910