CSHCS Contact Form

To help us respond to you as quickly and accurately as possible, please use our online contact form instead of our CHSCS phone line. Submitting the form gives us the details we need to route your request right away, which means faster response times and better support for you.”

1. Parent/Guardian Name (if client is a minor). Enter ‘N/A’ if the client is completing this form. *This question is required.

2. CSHCS Client Name *This question is required.

3. Client Date of Birth (mm/dd/yyyy) *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

4. CSHCS Client ID (leave blank if you do not have a client ID)

5. Email *This question is required. This question requires a valid email address.

6. Phone Number *This question is required.

7. Select the checkbox next to each topic where you need assistance. *This question is required.

Add Provider/Medical Specialist
Billing Question
Changes to my Insurance
I submitted paperwork and would like a status update
Pharmacy/Medication Question
Transportation Reimbursement Question
Update Address or Contact Information
Other

Please enter your updated address below.

Street Address *This question is required.

City *This question is required.

Zip Code *This question is required.

Please enter your insurance updates below

Are you adding or removing insurance? *This question is required.

Adding an insurance
Removing an insurance

Insurance Name

Medicaid Health Plan

Policy number

Group number

Subscriber name

Subscriber date of birth (mm/dd/yyyy) This question requires a valid date format of MM/DD/YYYY.

calendar

Subscriber social security number

Subscriber employer name

Name of insurance cancelled

What providers have changed?

	Provider Name	Specialty	Diagnosis	Add	Remove
	Provider Name	Specialty	Diagnosis	Add/Remove
Provider 1	Provider Name	Specialty	Diagnosis	Provider 1: Add/Remove : Add	Provider 1: Add/Remove : Remove
Provider 2	Provider Name	Specialty	Diagnosis	Provider 2: Add/Remove : Add	Provider 2: Add/Remove : Remove
Provider 3	Provider Name	Specialty	Diagnosis	Provider 3: Add/Remove : Add	Provider 3: Add/Remove : Remove
Provider 4	Provider Name	Specialty	Diagnosis	Provider 4: Add/Remove : Add	Provider 4: Add/Remove : Remove
Provider 5	Provider Name	Specialty	Diagnosis	Provider 5: Add/Remove : Add	Provider 5: Add/Remove : Remove

What is your billing question related to? *This question is required.

CSHCS payment agreement
Outstanding Medical Bill

Provider/hospital *This question is required.

Date of Service (mm/dd/yyyy) *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Please explain your current CSHCS billing or outstanding payment question/concern *This question is required.

Prescribing Doctor *This question is required.

Medication Name *This question is required.

Pharmacy Name *This question is required.

Pharmacy Phone Number *This question is required.

My pharmacy/medication question is about:

A Prior Authorization is required
I am unexpectedly being asked to pay for a medication or pharmacy supply
Other(please specify) Please enter an 'other' value for this selection. * This question is required.

What document was submitted? *This question is required.

Date Submitted (mm/dd/yyyy) *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Additional Comments *This question is required.

Transportation Reimbursement *This question is required.

I am requesting travel reimbursement to a provider already listed on my account.
I am requesting travel reimbursement to a provider NOT listed on my account.

Submit transportation reimbursement requests using this form.
NOTE: CSHCS does NOT reimburse Medicaid enrolled clients. If you/your child have Medicaid/Medicaid Health Plan, please contact your health plan’s beneficiary line for reimbursement help.
CSHCS provides transportation reimbursement for travel to appointments with authorized providers already on the account. Reimbursement will only be processed if a request is made within 90 days from the date of the appointment. Your signature will be required, and you will have to return the form to CSHCS staff for submission. Please note that reimbursement checks may take several months to be issued by the state.
Out of state travel MUST be prior-authorized BEFORE the travel takes place. Please call 517-335-9408 for assistance.

The provider must be listed on your CSHCS account prior to submitting a travel reimbursement request. Please scroll up to the top of this form and check the box next to "Add Provider/Medical Specialist" to add a new provider to your account.

Please add your question/concern to the box below. *This question is required.