IN 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.


1) Primary Practice

2) Secondary Practice

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

Selecting a new attachment replaces the current one.


December 2018
IN-EXCP-66
Provider Operations
P.O. Box 4135
Dayton, OH 45401-4135
Phone: 1-844-607-2829 Fax: 1-937-531-3910