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 (*)


New Providers Only *


Program Selection *


Are you currently contracted with an Independent Practice Association (IPA) or a Physician Hospital Organization (PHO)? *



Primary Practice Address






Agreement *


Agreement *