Caresource hierarchy form 2025

1. Click ‘Get Form’ to open the CareSource Provider/Group 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.
3. Select the appropriate action: Add a Provider, Delete a Provider, or Demographic Change. Provide additional details in the Notes section on Page 2 if necessary.
4. Complete the Group Information section, including Group IRS Name, DBA, TIN, NPI, and Medicare/Medicaid numbers.
5. Indicate your product type (e.g., Medicaid Only, SNP Only) and provide Office Contact details such as Name, Phone, and Email.
6. Fill out the Signatory section with your name, title, and email address. Ensure all address fields are completed accurately.
7. In the Provider Information section, enter details for each provider including Name/Deg, Address, Phone, NPI#, CAQH#, Medicaid#, Medicare#, and Specialty.
8. Finally, review all entries for accuracy before submitting via email or fax as indicated at the bottom of the form.

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