Forms

Claims forms:

Electronic Claims Enrollment Forms

Ambetter Provider Request for Reconsideration and Claim Dispute Form

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

Direct Deposit (EFT) FAQs

Direct Deposit (EFT) Enrollment Form

Address change forms:

W-9 Tax Form

Provider Information Form

Location Information Form

Credentialing forms:

Insurance Certificate Holder Request

Option forms:

Georgia Network Options Form

South Carolina Network Options Form

Tennessee Network Options Form

MultiPlan Auto Liability Option Form

Ambetter Enrollment Form

Forms

ActivHealthCare