Claims forms:
Electronic Claims Enrollment Forms Ambetter Provider Request for Reconsideration and Claim Dispute Form
Electronic Claims Enrollment Forms
Ambetter Provider Request for Reconsideration and Claim Dispute Form
Direct Deposit (Electronic Funds Transfer (EFT)) forms:
Direct Deposit (EFT) FAQs Direct Deposit (EFT) Enrollment Form
Direct Deposit (EFT) FAQs
Direct Deposit (EFT) Enrollment Form
Address change forms:
W-9 Tax Form Provider Information Form Location Information Form
W-9 Tax Form
Provider Information Form
Location Information Form
Credentialing forms:
Insurance Certificate Holder Request
Option forms:
Georgia Network Options Form South Carolina Network Options Form Tennessee Network Options Form MultiPlan Auto Liability Option Form Ambetter Enrollment Form
Georgia Network Options Form
South Carolina Network Options Form
Tennessee Network Options Form
MultiPlan Auto Liability Option Form
Ambetter Enrollment Form
1926 Northlake Parkway, Suite 100 Tucker, GA 30084
Phone 770.455.0040 Fax 770.455.6188 Toll Free 888.635.0459