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NOTICE OF DATA BREACH

We are sorry to tell you about a privacy event that impacted our vendor, Episource, LLC (“Episource” or “They”). Episource works with health plans, including Peach State Health Plan. This event may have involved your data. Click here to learn more about the data breach.
 

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What type of provider are you? required *
Please select an option below required *
Products Requested required * Please select all the products you would like included in your Agreement
What type of facility is this? required *

Before you fill out the form below, please review the Checklist for credentialing, download all required documents, and fill them out completely. Once you have completed your documents, be sure to finish the form below and upload your documents.

Before you fill out the form below, please review the Checklist for credentialing, download all required documents, and fill them out completely. Once you have completed your documents, be sure to finish the form below and upload your documents.

Please do not use dashes ("-")
Does your Organization have multiple Facility/Agency NPIs on this application? required *
Please enter your additional Facility/Agency NPIs that you are applying for delimited by a single comma. Please do not input Individual practitioner NPIs in this field.
Attach licenses, accreditations, certifications, enrollment letters, etc...
Attach licenses, accreditations, certifications, enrollment letters, etc...
Attach licenses, accreditations, certifications, enrollment letters, etc...