CareSource

Nevada Non-participating Provider Profile

Please complete this form for the provider listed. CareSource is unable to process requests for ID without accurate information. A W-9 is needed with the submitted claim.

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.


December 2025
NV-MED-P-3979036
Provider Operations
P.O. Box 4135
Dayton, OH 45401-4135
Phone: 1-800-488-0134 Fax: 1-937-531-3910