Join Our Network

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.

To join our Ambetter Behavioral Health Network, please complete theBehavioral Health Join our Network form.

Required fields are marked with an asterisk (*)

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

An option from Are you currently contracted with an Independent Practice Association (IPA) or a Physician Hospital Organization (PHO)? must be checked before submitting.

Confirm Enter IPA or PHO Name must be completed properly before submitting.

Adaptive AidesMedical Equipment

Certified Clinical Nurse Specialist

Consumer Directed Services CDS

Critical Care Intensivist

Free Standing Rehabilitation Facility

Free Standing Renal Dialysis Facility

OBNurse Midwife Specialty Types

Personal Care Services PCS

Primary Home CareNursing Services

Confirm Sub-Specialty must be completed properly before submitting.

Confirm Enter Provider Name must be completed properly before submitting.

Confirm Enter Group Practice Name must be completed properly before submitting.

Enter Provider Tax ID Number (e.g. 999999999) *

Confirm Enter Provider Tax ID Number (e.g. 999999999) must be completed properly before submitting.

Confirm Enter Provider NPI Number must be completed properly before submitting.

Confirm Enter Group NPI Number must be completed properly before submitting.

Confirm Primary Practice Address must be completed properly before submitting.

Confirm City must be completed properly before submitting.

Confirm Zip Code must be completed properly before submitting.

Confirm County must be completed properly before submitting.

Confirm Contact Name must be completed properly before submitting.

Confirm Contact Number must be completed properly before submitting.

Confirm Contact Email must be completed properly before submitting.

I understand this inquiry does not guarantee my participation in the Peach State Health Plan network.

At least one checkbox from Agreement must be checked before submitting.

I understand that failure to complete this inquiry accurately and completely will result in the delay of evaluating my request.

At least one checkbox from Agreement must be checked before submitting.

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