CareSource ProviderGroup Change Request Form 2026

1. Click ‘Get Form’ to open the CareSource ProviderGroup Change Request Form in the editor.
2. Begin by filling in the date and your PR Representative's name at the top of the form. This establishes a clear point of contact for your request.
3. Select the appropriate checkbox for your request: Add a Provider, Delete a Provider, or Demographic Change. Be sure to provide any additional details in the Notes section on Page 2.
4. Complete the Group information fields including IRS Name, DBA, TIN, NPI, Medicare and Medicaid numbers. Accurate data here is crucial for processing.
5. Indicate your product type by checking one of the options under Product: Medicaid Only, Medicaid and SNP, SNP Only, or MyCare.
6. Fill out the Office Contact section with a contact name, phone number, and email address to ensure effective communication.
7. Provide necessary Contractual Updates and Remit Address details as required. If they are the same as above, simply check that box.
8. Finally, review all entries for accuracy before submitting your form via email or fax as indicated at the bottom of the document.

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