CareSource Life Services® Request Info

CareSource Life Services® is a program** that provides non-medical support that can include assistance with housing, food insecurity and employment. Use this form to refer patients to this program.

Criteria for referring to CareSource Life Services:

  • CareSource Ohio Medicaid or Marketplace member
  • CareSource member or parent/legal guardian of a minor child who is a CareSource Ohio Medicaid or Marketplace member
  • 14 years or older
  • Member has interest in opting in to the CareSource Life Services program

Complete the following fields:

This number is found on the front of your Member ID Card.

THIS IS A REFERRAL FORM, NOT AN ENROLLMENT APPLICATION

**Program available to Ohio Medicaid or Marketplace members only
OH-Multi-P-1250234