Ancillary and Facility Provider Credentialing Application 2026

1. Click ‘Get Form’ to open the Ancillary and Facility Provider Credentialing Application in our editor.
2. Begin by filling out the Provider Demographic Information section. Enter your Facility/Group Name, Professional Category, Address, Phone Number, and Email. Ensure all fields are completed accurately.
3. Attach the required documents listed at the beginning of the application. Use our platform's upload feature to easily attach copies of your Georgia State License, Quality Improvement Plan, and other necessary certifications.
4. Proceed to the Licenses/Certifications/Specialties section. List all current and past licenses along with their respective details such as STATE, LICENSE NO., DATE ISSUED, and EXPIRATION DATE.
5. Complete the Liability Coverage section by providing your insurance company name, policy number, amount of coverage, and relevant dates.
6. Finally, review the Release of Information and Attestation section. Sign and date the application to confirm that all information is accurate before submitting it through our platform.

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