Forms

Appeals and Reconsiderations:

• Ambetter Provider Request for Reconsideration and Claim Dispute Forms:

  • GA Dispute Form

  • How To Fill Out A Reconsideration and Claim Dispute - GA

  • NC Dispute Form

  • How To Fill Out A Reconsideration and Claim Dispute - NC

  • SC Dispute Form

  • How To Fill Out A Reconsideration and Claim Dispute - SC

  • TN Dispute Form

  • How To Fill Out A Reconsideration and Claim Dispute - TN

• CareSource Appeals Form

• How to File CareSource Appeals (link is external)
   

Direct Deposit (Electronic Funds Transfer (EFT)) forms:

• Direct Deposit (EFT) FAQs

• Direct Deposit (EFT) Enrollment Form
  Note: All applicable lines must be completed. Complete the form, then print and sign.
   

Electronic Claims Enrollment Forms:

• Electronic Claims Enrollment Forms (EDI)
   

Address change forms:

• W-9 Tax Form

• Provider Information Form

• Location Information Form
   

Credentialing forms:

• Insurance Certificate Holder Request
   

Network option forms:

• Georgia Network Options Form

• North Carolina Network Options Form

• South Carolina Network Options Form

• Tennessee Network Options Form

• Ambetter Enrollment Form