Skip to main content
Georgia Department of Community Health logo Georgia MMIS
Search
  Sunday, August 30, 2015
Skip to Provider Enrollment Subsystem Menu
»

User Information

  
Login/Manage Account
Login

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

 

PDF Reader Required
NOTE: If you don't have a PDF reader already installed, Adobe Acrobat Reader is required to view these documents. Click here to obtain the latest version of the free Adobe Reader.
File Download Issues
Some users may have difficulty downloading files. Often this is caused by pop-up windows being blocked or by security settings in the browser. Click here for help with download issues.

Enrollment Forms (22 rows returned) List
 
»

Enrollment Forms (22 rows returned)

 
 TitleFile TypeSize (KB)Release Date 
AUTHORIZATION AND RELEASE OF INFORMATION FORMPDF207.6007/15/2015 
Disclosure of Ownership Provider OnlyPDF202.7005/13/2015 
EFT Reassociation Sample LetterPDF185.9003/20/2014 
Electronic Funds Transfer Agreement (EFT) WebPortal Instructions PDF64.6003/20/2014 
Fax Cover Sheet for Provider Enrollment (Paperless Initiative)PDF178.4005/21/2015 
Medicaid and PeachCare for Kids Provider Information Change FormPDF341.1005/13/2015 
NPI Submittal Form PDF217.2005/13/2015 
Power of Attorney for PayeePDF10.2011/12/2010 
Power of Attorney Instructions (Individual Practitioner)PDF4506.9003/01/2011 
Pregnancy Related Services QuestionnairePDF493.8010/27/2010 
Professional Liability Claims Information FormPDF41.1003/29/2013 
Provider FEIN Change Request Fill in FormPDF130.1005/13/2015 
Provider Reactivation Request Fill-In FormPDF174.3005/13/2015 
Required Documentation to enroll with Georgia MedicaidPDF702.5005/12/2015 
Statement of ParticipationPDF31.5011/12/2010 
Step By Step Instructions on How to Complete the Power of Attorney Form (Facility)PDF2101.9005/11/2011 
Step By Step Instructions on How to Complete the Power of Attorney Form (Individual Practitioner)PDF2892.3005/11/2011 
Step By Step Instructions on How to Complete the W9 Form (Facility)PDF1746.8005/11/2011 
Step By Step Instructions on How to Complete the W9 Form (Individual Practitioner Paying the Social Security Number)PDF1431.3005/11/2011 
Step By Step Instructions on How to Complete the W9 Form (Individual Practitioner)PDF1697.5005/11/2011 
W-9 InstructionsPDF42.5005/13/2015 
W9 FormPDF84.4004/16/2012 
English | Espa├▒ol | Accessibility | Privacy | AMA & ADA Copyright Report Fraud
© 2003-2015 Hewlett-Packard Development Company, L.P.