Peach State Health PlanForms
Phone Numbers
Provider Services
(866) 874-0633
Monday - Friday
7 a.m. to 7 p.m.Provider Portal
To enter our secure portal click on the login button. If you need a username and password click on the register button.
Resources
Manuals
Forms
Preferred Drug Lists
Prior Authorization Forms
EDI Documenation
Newsletters
Helpful Links
DCH Notifications
ArchivesYou will need Adobe Reader to open PDFs on this site.
Download the free version of Reader
Contracts
Credentialing Application
Please complete the form for your specialty.
- Allied Healthcare Professional Credentialing Application – Part 1 (PDF)
- Allied Healthcare Professional Credentialing Application – Part 2 (PDF)
- Ancillary and Facility Provider Credentialing Application (PDF)
- CAQH Provider Data (PDF)
- Credentialing Application Checklist (PDF)
- Practitioner Credentialing Application – Part 1 (PDF)
- Practitioner Credentialing Application – Part 2 (PDF)
Claims Related
Medical Management Forms
- Case Management Fax Form (PDF)
- Delivery_Notification_Form (PDF)
- Lead Risk Assessment Questionnaire Form (PDF)
- Managed Care Hospice Election Revocation Form (PDF)
- Pregnancy_Incentive_Reimbursement_Form (PDF)
- Prenatal Vitamin Program (PDF)
- Prior_Authorization_Form_(PDF)
- Provider Notification Form – Diabetes (Diabetes/Chronic Kidney Disease Referral Form) (PDF)
- Therapy Referral Form (PDF)
- Tuberculosis Risk Assessment Questionnaire (PDF)
- Universal Pregnancy Notification Form (PDF)
Miscellaneous