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Contract Request Form

Thank you for your interest in joining our network. Completion of the below application form indicates your interest only. Your inquiry will be evaluated based on the needs our membership in your practice area. You will be contacted by our Network Development and Contracting Team regarding your request. Please allow 7-10 business days for our evaluation and response.

Effective 8/1/2015, the Georgia Department of Community Health (DCH) will require all Medicaid providers seeking to enroll in the Peach State Health Plan Provider Network or any other CMO network to be credentialed by the new Centralized Credentialing Verification Organization (CVO). Therefore, it will also be necessary for you to submit a credentialing application to the CVO prior to your acceptance in to our Provider Network. For further information regarding the new CVO credentialing process, please visit DCH provider portal: www.mmis.georgia.gov or contact HP Provider Call Center at 1-800-766-4456.

Required fields are marked with an asterisk (*)

What type of provider are you? required * Solo: Practitioner billing with your own Tax ID#. (If you are a provider joining an existing contract please click on Group Practice, and select 'I have a contract..') Group Practice Facility

Error: This field is required.

PAI Qualtrics Survey Link

Please select an option below required * I do not have a contract and need to apply I have a contract, or want to add provider(s) to an existing Group or Facility contract

Error: This field is required.

Solo Provider

Program Selection required * Medicaid Medicare Both

Error: This field is required.

Select Your Primary Specialty *

Error: This field is required.

Sub-Specialty

Group Practice or Facility/Agency Name *

Error: This field is required.

Legal Entity Name *

Error: This field is required.

As listed on the Form W-9

DBA Name

Tax ID Contracting For *

Error: This field is required.

Numbers only

Provider First Name *

Error: This field is required.

Provider Last Name *

Error: This field is required.

Individual NPI *

Error: This field is required.

Numbers only. Enter all 9's if you don't have an NPI

Practitioner Taxonomy

Practitioner GA Medicaid *

Error: This field is required.

The GA Medicaid ID consists of 9 numbers and 1 letter.

Practitioner Medicare

City *

Error: This field is required.

State *

Error: This field is required.

ZIP Code *

Error: This field is required.

Primary Practice Street Address *

Error: This field is required.

Primary Practice City *

Error: This field is required.

Primary Practice State *

Error: This field is required.

Primary Practice ZIP Code *

Error: This field is required.

Primary Practice County *

Error: This field is required.

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Error: This field is required.

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Fax

Error: This field is required.

Contact Email *

Error: This field is required.

Provider Email *

Error: This field is required.

Before submitting this form, please download the documents listed below by right-clicking and choosing "Save link as" or "Save target as." Once the documents are complete, upload to the corresponding upload option at the end of this page.

Disclosure of Ownership Form (PDF)
W-9 Form (PDF)

PAI Qualtrics Survey Link

If you have selected Medicare, please be sure to upload your CMS Medicare Approval Letter.

Disclosure of Ownership Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Group - New Contract

Program Selection required * Medicaid Medicare Both

Error: This field is required.

Practitioner First Name *

Error: This field is required.

Practitioner Last Name *

Error: This field is required.

Practitioner NPI Number *

Error: This field is required.

Georgia Medicaid ID Number *

Error: This field is required.

Group Practice or Facility Name *

Error: This field is required.

Legal Entity Name *

Error: This field is required.

As listed on the Form W-9

DBA Name

Tax ID Contracting For *

Error: This field is required.

Numbers only

Group Or Facility Primary NPI *

Error: This field is required.

Numbers only. Enter all 9's if you don’t have an NPI

Organization GA Medicaid *

Error: This field is required.

The GA Medicaid ID consists of 9 numbers and 1 letter.

Organization Medicare

Organization Taxonomy

Practice Address *

Error: This field is required.

City *

Error: This field is required.

State *

Error: This field is required.

ZIP Code *

Error: This field is required.

Primary Practice Street Address *

Error: This field is required.

Primary Practice City *

Error: This field is required.

Primary Practice State *

Error: This field is required.

Primary Practice ZIP Code *

Error: This field is required.

Primary Practice County *

Error: This field is required.

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Error: This field is required.

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Fax

Error: This field is required.

Contact Email *

Error: This field is required.

Provider Email *

Error: This field is required.

Number of Practitioners Joining *

Error: This field is required.

Disclosure of Ownership Form (PDF)
W-9 Form (PDF)

PAI Qualtrics Survey Link

If you have selected Medicare, please be sure to upload your CMS Medicare Approval Letter.

Disclosure of Ownership Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Group - Existing Contract

Program Selection required * Medicaid Medicare Both

Error: This field is required.

Practitioner First Name *

Error: This field is required.

Practitioner Last Name *

Error: This field is required.

Practitioner NPI Number *

Error: This field is required.

Georgia Medicaid ID Number *

Error: This field is required.

Group Practice or Facility Name *

Error: This field is required.

Legal Entity Name *

Error: This field is required.

As listed on the Form W-9

DBA Name

Tax ID Contracting For *

Error: This field is required.

Numbers only

Group Or Facility Primary NPI *

Error: This field is required.

Numbers only. Enter all 9's if you don’t have an NPI

Organization GA Medicaid *

Error: This field is required.

The GA Medicaid ID consists of 9 numbers and 1 letter.

Organization Medicare

Organization Taxonomy

Practice Address *

Error: This field is required.

City *

Error: This field is required.

State *

Error: This field is required.

ZIP Code *

Error: This field is required.

Primary Practice County *

Error: This field is required.

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Fax

Error: This field is required.

Contact Email *

Error: This field is required.

Provider Email *

Error: This field is required.

Number of Practitioners Joining *

Error: This field is required.

Disclosure of Ownership Form (PDF)
W-9 Form (PDF)

PAI Qualtrics Survey Link

If you have selected Medicare, please be sure to upload your CMS Medicare Approval Letter.

Disclosure of Ownership Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Facility - New Contract

Program Selection required * Medicaid Medicare Both

Error: This field is required.

Group Practice or Facility/Agency Name *

Error: This field is required.

Legal Entity Name *

Error: This field is required.

As listed on the Form W-9

DBA Name

Provider First Name *

Error: This field is required.

Provider Last Name *

Error: This field is required.

Tax ID Contracting For *

Error: This field is required.

Numbers only

Group Or Facility Primary NPI *

Error: This field is required.

Numbers only. Enter all 9's if you don’t have an NPI

Does your Organization have multiple Facility NPIs on this application? required * Yes No

Error: This field is required.

Additional NPIs Please enter your additional Facility/Agency NPIs that you are applying for separated by a single comma. Please do not input Individual practitioner NPIs in this field.

Organization GA Medicaid *

Error: This field is required.

The GA Medicaid ID consists of 9 numbers and 1 letter.

Organization Medicare

Organization Taxonomy

Correspondence Address *

Error: This field is required.

City *

Error: This field is required.

State *

Error: This field is required.

ZIP Code *

Error: This field is required.

Primary Practice Street Address *

Error: This field is required.

Primary Practice City *

Error: This field is required.

Primary Practice State *

Error: This field is required.

Primary Practice ZIP Code *

Error: This field is required.

Primary Practice County *

Error: This field is required.

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Error: This field is required.

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Fax

Error: This field is required.

Contact Email *

Error: This field is required.

Provider Email *

Error: This field is required.

Number of Practitioners Joining *

Error: This field is required.

Number of Facilities Joining *

Error: This field is required.

Disclosure of Ownership Form (PDF)
W-9 Form (PDF)

PAI Qualtrics Survey Link

If you have selected Medicare, please be sure to upload your CMS Medicare Approval Letter.

Disclosure of Ownership Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Facility - Existing Contract

Program Selection required * Medicaid Medicare Both

Error: This field is required.

Group Practice or Facility Name *

Error: This field is required.

Legal Entity Name *

Error: This field is required.

As listed on the Form W-9

DBA Name

Provider First Name *

Error: This field is required.

Provider Last Name *

Error: This field is required.

Tax ID Contracted For *

Error: This field is required.

Numbers only

Group Or Facility Primary NPI *

Error: This field is required.

Numbers only. Enter all 9's if you don’t have an NPI

Does your Organization have multiple Facility NPIs on this application? required * Yes No

Error: This field is required.

Additional NPIs Please enter your additional Facility/Agency NPIs that you are applying for separated by a single comma. Please do not input Individual practitioner NPIs in this field.

Organization GA Medicaid *

Error: This field is required.

The GA Medicaid ID consists of 9 numbers and 1 letter.

Organization Medicare

Organization Taxonomy

Correspondence Address *

Error: This field is required.

City *

Error: This field is required.

State *

Error: This field is required.

ZIP Code *

Error: This field is required.

Primary Practice County *

Error: This field is required.

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Fax

Error: This field is required.

Contact Email *

Error: This field is required.

Provider Email *

Error: This field is required.

Number of Practitioners Joining *

Error: This field is required.

Number of Facilities Joining *

Error: This field is required.

Disclosure of Ownership Form (PDF)
W-9 Form (PDF)

PAI Qualtrics Survey Link

If you have selected Medicare, please be sure to upload your CMS Medicare Approval Letter.

Disclosure of Ownership Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

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Member Services
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We are closed on holidays.

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