Forms

Appeals and Reconsiderations:

• Ambetter Provider Request for Reconsideration and Claim Dispute Form

• CareSource Appeals Form
  

• How to File CareSource Appeals

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