Join Our Network

Network Participation Request

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.

Required fields are marked with an asterisk (*)

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

Yes No

Enter IPA or PHO Name *

Select Your Primary Specialty *

Sub-Specialty

Enter Provider Name *

Enter Group Practice Name *

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

Enter Provider NPI Number *

Enter Group NPI Number

Primary Practice Address *

City *

State *

Zip Code *

County

Contact Name *

Contact Number *

Contact Email *

Agreement *

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

Agreement *

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

This field is for validation purposes and should be left unchanged.