Forms

Claims forms:

Georgia Electronic Claims Enrollment Forms

Other States - Electronic Claims Enrollment Forms

Ambetter Provider Request for Reconsideration and Claim Dispute Form

Georgia 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:

MultiPlan Auto Liability Option Form

Prime Health Services, Inc. Network Option Form

Ambetter Enrollment Form

Forms

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