Life Services^® Ohio Referral Form

If you would like to learn more about CareSource Life Services, please fill out the form below. Note: You don’t have to enroll.

You also can reach us at 1-844-543-7378 (TTY: 771) or by email at LifeServices@CareSource.com. We are open Monday through Friday, 8 a.m. – 5 p.m. We look forward to hearing from you!

Member First Name:

Member Last Name:

Please enter your Member ID or Recipient ID

Address:

City:

State:

ZIP Code:

County:

Phone:

Email:

I am interested in CareSource Life Services as a:

CareSource Member Employer Community Organization

Name of Employer

Name of Community Organization

Name of person completing the form

Contact number of person completing the form

I would like to receive email from CareSource.
I would like a CareSource representative to call me.
I would like to receive information about CareSource Life Services through the mail.

I am interested in CareSource Life Services for (please check all that apply):

Education Goal
Employment Goal
Linkage to Community Resources (For example: food assistance resources, transportation resources, housing resources, etc.)

This is NOT an Enrollment Form

OH-MULTI-M-2282823 ODM Approved: 9/14/2023

Life Services® Ohio Referral Form

This is NOT an Enrollment Form

Life Services^® Ohio Referral Form