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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: P.O. Box 52000, MC0109, Phoenix, AZ 850722000 Fax Number: 18556337673 You may also

How to fill out care source request for

To fill out a Care Source request, follow these steps:

1. Start by gathering all necessary information and documentation such as your personal details, contact information, and any relevant medical records or prescriptions.
2. Visit the Care Source website or contact their customer service to obtain the official request form. Make sure you have the latest version of the form to ensure accuracy.
3. Fill out the requested information on the form accurately and completely. This may include providing details about your current medical condition, the type of services or treatments you are seeking, and any other relevant information requested.
4. If necessary, attach any supporting documents or medical records that may help support your request. This could include doctor's letters, test results, or referral forms.
5. Double-check your completed form for any errors or omissions. Ensure that all the required fields have been filled correctly and review your responses for accuracy.
6. Once you are satisfied with the completed form, submit it according to the instructions provided by Care Source. This may include mailing the form, submitting it online, or faxing it to the appropriate department.

Who needs a Care Source request?

A Care Source request may be needed by individuals who are seeking healthcare services and coverage from Care Source. This could include:

1. Individuals who are looking for health insurance coverage and want to apply for a Care Source plan.
2. Existing Care Source members who require additional services, treatments, or prescriptions that require prior authorization or approval.
3. Patients who need to request specific medical services, treatments, or procedures that may require additional review or approval from Care Source.

In all cases, it is important to carefully fill out the Care Source request form and provide any necessary supporting documentation to ensure timely and accurate processing of your request.

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