Re-Credentialing Application - GEORGIA

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Re-Credentialing Application
	Re-Credentialing Checklist A provider checklist to ensure everything is included when the application is returned.
	Georgia Uniform Healthcare Practitioner Credentialing Application Form for Reappointment Part 1 This is a fillable Word document. This form is required by the State of Georgia.
	Georgia Uniform Healthcare Practitioner Credentialing Application Form for Reappointment Part 2 This is a fillable Word document. This form is required by the State of Georgia.
	Re-credentialing Application Part 3 All information on this page is required for information verification.
	Re-credentialing Application Part 4 Includes questions pertaining to each individual practice site for a particular provider (Name of practice, office hours, office location, office size, etc.).
	Patient Feedback Survey
	Provider Satisfaction Survey
	Release Authorization Signature and date verifying that all information is true and complete.
	Business Associate Agreement Terms of business relationship with ActivHealthCare. Must agree, sign and date.
	Provider Agreement Terms of provider membership with ActivHealthCare. Must agree, sign and date.
	Certificate Holder Request Request from your insurance company to list ActivHealthCare as a certificate holder and verification of your professional liability insurance coverage as well as your medical malpractice claims history.
	W-9 Tax Form W-9 tax form to be completed and submitted initially and whenever there is a tax related change.