Initial Credentialing Application - GEORGIA

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Initial Application
	Requirements for Participation Applicants must meet all standards that are listed to be considered for participation.
	Initial Checklist A provider checklist to ensure everything is included when the application is returned.
	Georgia Uniform Healthcare Practitioner Credentialing Application Form Part 1 Standardized application for healthcare entities required by the State of Georgia as part of the credentialing process. This is a fillable Word document.
	Georgia Uniform Healthcare Practitioner Credentialing Application Form Part 2 Part 2 of the standardized application for healthcare entities required by the State of Georgia as part of the credentialing process. This is a fillable Word document.
	ActivHealthCare Initial Application Part 3 ActivHealthCare form containing additional questions needed for the credentialing process.
	ActivHealthCare Initial Application Part 4 ActivHealthCare form containing additional questions needed for the credentialing process.
	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. This is a fillable Word document.