Georgia



Online Credentialing Application Now Available


You now have the option of submitting your credentialing application online or using the paper documents below. To complete the online application, click here


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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.
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.