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.
