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  Wednesday, February 21, 2024
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Forms (27 rows returned) List
 
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Forms (27 rows returned)

 
 TitleFile TypeSize (KB)Release Date 
Access to Initial Application LettersPDF298.501/15/2020 
Appendix FF - Notice of Intent to Become a CCSP Service ProviderPDF292.212/05/2022 
Appendix GG-Application ChecklistPDF199.612/05/2022 
Authorization and Release of Information FormPDF156.609/03/2019 
CCSP & Source Standard Assurances FormPDF62.802/03/2020 
CVO Required Documents ChecklistPDF75.905/31/2017 
Delegated Credentialing Entity Attestation FormPDF91.803/22/2018 
Disclosure of Ownership and Control Interest Statement - Contractors OnlyPDF648.904/09/2019 
Disclosure of Ownership and Control Interest Statement - Contractors Only-NEMTPDF635.704/09/2019 
Disclosure of Ownership and Control Interest Statement - Providers OnlyPDF611.604/09/2019 
Disclosure of Ownership and Control Interest Statement - Trading Partners OnlyPDF630.804/09/2019 
Durable Medical Equipment (DME) Licensure Exemption Attestation FormPDF155.205/17/2018 
Electronic Funds Transfer Agreement (EFT) Web Portal InstructionsPDF64.605/31/2017 
Hardship Waiver of Application FeePDF23.905/12/2014 
ICWP Provider Enrollment ChecklistPDF242.204/26/2023 
LEA Attestation FormPDF246.503/18/2016 
Power of Attorney for Payee (POA)PDF12.509/25/2013 
Power of Attorney Instructions (Individual Practitioner and Facility)PDF689.703/31/2022 
Pregnancy Related Services QuestionnairePDF493.805/31/2017 
Professional Liability Claims Information FormPDF41.105/31/2017 
Provider Enrollment CoversheetsPDF750.604/24/2023 
Required Documentation to enroll with Georgia MedicaidPDF468.306/20/2019 
Step By Step Instructions on How to Complete the W9 Form (Facility)PDF1746.805/31/2017 
Step By Step Instructions on How to Complete the W9 Form (Individual Practitioner Paying the Social Security Number)PDF1431.305/31/2017 
Step By Step Instructions on How to Complete the W9 Form (Individual Practitioner)PDF1697.505/31/2017 
W-9 InstructionsPDF42.505/31/2017 
W9 FormPDF84.405/31/2017 
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