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 7:00 a.m. to 3:30 p.m. Central Time (CT). Submissions received outside of business hours will be processed during the next business day.
