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  Wednesday, June 20, 2018
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Provider Enrollment

The Provider Enrollment Unit enrolls qualified providers to receive Medicaid reimbursement for services rendered to Medicaid members. Providers wanting to enroll in the Georgia Medicaid program can easily do so online using the Enrollment Wizard found within the Provider Enrollment menu. This online enrollment system provides the option to upload electronic attachments against a submitted application. Submitted applications, including any attachments, are instantly affiliated to the provider's enrollment file to be reviewed by the Provider Enrollment Unit. Upon completion of the enrollment process, approved providers are issued a Medicaid provider number and able to participate in the Georgia Medicaid program.


The Provider Enrollment Unit is also available to assist the provider with enrollment issues such as change of address, change of ownership, and reenrollment issues.


The Provider Enrollment Unit can be reached at the following:


  • Fill out the Contact Us form.
  • Call the local number (770) 325-9600
  • Call the toll-free number (800) 766-4456


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Forms (27 rows returned) List

Forms (27 rows returned)

 TitleFile TypeSize (KB)Release Date 
Appendix FF - Notice of Intent to Become a CCSP Service ProviderPDF315.102/16/2018 
Appendix HH - CCSP Application ChecklistPDF250.902/16/2018 
Attestation Form for Specialty Provider for Autism ServicesPDF252.403/22/2018 
Authorization and Release of Information FormPDF207.605/31/2017 
CCSP Standard Assurance DocumentationPDF129.202/16/2018 
CVO Required Documents ChecklistPDF75.905/31/2017 
Delegated Credentialing Entity Attestation FormPDF91.803/22/2018 
Disclosure of Ownership Control Interest Statement Contractors OnlyPDF437.505/31/2017 
Disclosure of Ownership Provider OnlyPDF202.705/13/2015 
Disclosure of Ownership Trading Partners Only - RevisedPDF462.805/31/2017 
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 
LEA Attestation FormPDF246.503/18/2016 
Power of Attorney for Payee (POA)PDF12.509/25/2013 
Power of Attorney Instructions (Individual Practitioner)PDF2612.105/31/2017 
Pregnancy Related Services QuestionnairePDF493.805/31/2017 
Professional Liability Claims Information FormPDF41.105/31/2017 
Provider Enrollment CoversheetsPDF1505.703/05/2018 
Required Documentation to enroll with Georgia MedicaidPDF702.505/31/2017 
Step By Step Instructions on How to Complete the Power of Attorney Form (Facility)PDF2101.905/31/2017 
Step By Step Instructions on How to Complete the Power of Attorney Form (Individual Practitioner)PDF2892.305/31/2017 
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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