Forms

Claims forms:

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

Ambetter Enrollment Form