Initial Credentialing Application - GEORGIA

Adobe Acrobat Reader
	Download Adobe Acrobat Reader Adobe Acrobat or Adobe Acrobat Reader is required to open the .PDF files listed below.
Initial Application
	Initial Checklist A provider checklist to ensure everything is included when the application is returned.
	Requirements for Participation Applicants must meet all standards that are listed to be considered for participation.
	Georgia Uniform Healthcare Practitioner Credentialing Application Standardized application for healthcare entities required by the State of Georgia as part of the credentialing process. Both Parts 1 and 2 are fillable Word documents. Part 1 Form Part 2 Form
	Provider Information Form
	Location Information Form A Location Information Form should be completed for each office location.
	Release Authorization Signature and date verifying that all information is true and complete.
	Provider Agreement Terms of provider membership with ActivHealthCare. Must agree, sign and date.
	Business Associate Agreement Terms of business relationship 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.
	CMS Worksheet Form for determining business interests.
	W-9 Tax Form W-9 tax form to be completed and submitted initially and whenever there is a tax related change. This is a fillable PDF document.