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:

Member First Name:

Member Last Name:

Member ID number (from card):

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

Member Address:

Member City:

Member State:

Member ZIP:

Member County:

Member Phone:

Member Email:

Member Age:

Referring Physician or Medical Facility Name:

Referring Physician Phone Number:

Additional Comments About the Referral:

THIS IS A REFERRAL FORM, NOT AN ENROLLMENT APPLICATION

**Program available to Ohio Medicaid or Marketplace members only

OH-Multi-P-1250234

CareSource Life Services® Request Info

THIS IS A REFERRAL FORM, NOT AN ENROLLMENT APPLICATION

CareSource Life Services^® Request Info