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Forms

Appeals and Reconsiderations:

  • Ambetter Provider Request for Reconsideration and Claim Dispute Form

  • CareSource Appeals Form

  • How to File CareSource Appeals

Direct Deposit (Electronic Funds Transfer (EFT)) forms:

  • Direct Deposit (EFT) FAQs

  • Direct Deposit (EFT) Enrollment Form

Electronic Claims Enrollment Forms:

  • Electronic Claims Enrollment Forms (EDI)

Address change forms:

  • W-9 Tax Form

  • Provider Information Form

  • Location Information Form

Credentialing forms:

  • Insurance Certificate Holder Request

Network option forms:

  • Georgia Network Options Form

  • North Carolina Network Options Form

  • South Carolina Network Options Form

  • Tennessee Network Options Form

  • Ambetter Enrollment Form

ActivHealthCare

1926 Northlake Parkway, Suite 100
Tucker, GA 30084

Phone 770.455.0040
Fax 770.455.6188

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