Skip to Main Content

Contract Request Form

Thank you for your interest in joining our network. Completion of the below application form indicates your interest only. Your inquiry will be evaluated based on the needs our membership in your practice area. You will be contacted by our Network Development and Contracting Team regarding your request. Please allow 2-3 business days for our evaluation and response.

Effective 8/1/2015, the Georgia Department of Community Health (DCH) will require all Medicaid providers seeking to enroll in the Peach State Health Plan Provider Network or any other CMO network to be credentialed by the new Centralized Credentialing Verification Organization (CVO).  Therefore, it will also be necessary for you to submit a credentialing application to the CVO prior to your acceptance in to our Provider Network. For further information regarding the new CVO credentialing process, please visit DCH provider portal: www.mmis.georgia.gov or contact HP Provider Call Center at 1-800-766-4456.

Required fields are marked with an asterisk (*)

Program Selection*
As listed on the Form W-9
Numbers only
Numbers only. Enter all 9's if you don't have an NPI
Numbers only

Before submitting this form, please download the documents listed below by right-clicking and choosing "Save link as" or "Save target as." Once the documents are complete, upload to the corresponding upload option at the end of this page.

As listed on the Form W-9
Numbers only
Numbers only. Enter all 9's if you don’t have an NPI
Numbers only

Before submitting this form, please download the documents listed below by right-clicking and choosing "Save link as" or "Save target as." Once the documents are complete, upload to the corresponding upload option at the end of this page.

As listed on the Form W-9
Numbers only
Numbers only. Enter all 9's if you don’t have an NPI
Numbers only

Before submitting this form, please download the documents listed below by right-clicking and choosing "Save link as" or "Save target as." Once the documents are complete, upload to the corresponding upload option at the end of this page.

If you are only submitting the direct roster for several practitioners please us the upload option for the New Practitioner Enrollment form to attach the roster.

As listed on the Form W-9
Numbers only
Numbers only. Enter all 9's if you don’t have an NPI
Please enter your additional Facility/Agency NPIs that you are applying for separated by a single comma. Please do not input Individual practitioner NPIs in this field.
Numbers only

Before submitting this form, please download the documents listed below by right-clicking and choosing "Save link as" or "Save target as." Once the documents are complete, upload to the corresponding upload option at the end of this page.

As listed on the Form W-9
Numbers only
Numbers only. Enter all 9's if you don’t have an NPI
Please enter your additional Facility/Agency NPIs that you are applying for separated by a single comma. Please do not input Individual practitioner NPIs in this field.
Numbers only

Before submitting this form, please download the documents listed below by right-clicking and choosing "Save link as" or "Save target as." Once the documents are complete, upload to the corresponding upload option at the end of this page.