Georgia
Re-Credentialing Application Now Available OnlineYou now have the option of submitting your re-credentialing application online or using the paper documents below. To complete the online application, click here |
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Adobe Acrobat Reader Adobe Acrobat or Adobe Acrobat Reader is required to open the .PDF files listed below. |
Re-Credentialing Application |
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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 Both forms are fillable Word documents required by the State of Georgia. | |
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Provider Information Form |
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Location Information Update Form A Location Information Form should be completed for each office location. |
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Patient Feedback Survey |
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Provider Satisfaction Survey |
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Release Authorization Signature and date verifying that all information is true and complete. |
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Provider
Agreement Terms of provider membership with ActivHealthCare. Must agree, sign and date. |
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Business
Associate Agreement Terms of business relationship with ActivHealthCare. Must agree, sign and date. |
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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. |
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CMS Worksheet Form for determining business interests. |
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W-9 Tax Form W-9 tax form to be completed and submitted initially and whenever there is a tax related change. |