Get Provider Reactivation Request Form

This guide provides clear and supportive instructions on how to successfully complete the Provider Reactivation Request Form online. By following the steps outlined below, users can ensure that their requests for reactivation are processed efficiently.

Follow the steps to complete the Provider Reactivation Request Form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In the box located at the top right-hand corner of the form under the Doc Type number (4119), input the Medicaid Provider ID, including any letter suffix. Remember, only one Medicaid ID is permitted per form. If you possess multiple IDs, each one will need its own separate form.
3. Enter the Rendering Provider’s information including the Provider’s Name, the GA Medicaid Contract(s) you wish to reactivate (for example, 430, 300, etc.), as well as the NPI and Tax ID, both of which are required for all reactivation requests.
4. Complete the contact information for the individual or organization that is making the request. Ensure to provide accurate details for the Name of Person Submitting Request, Facility/Organization/Practice Name, Mailing Address, City, State, Zip, Contact Phone Number, and Contact Email Address.
5. In the Certification and Signature section, print the name of the authorized individual, include their title, sign the form, and provide the date of submission. Ensure that all fields marked with an asterisk (*) are filled out as they are mandatory.
6. Lastly, submit the completed form by faxing it to HP Enterprise Services, Attn: Provider Enrollment Unit at the fax number 1-866-483-1045. Ensure that the form is correctly signed and all required fields are complete to avoid processing delays.

Complete your Provider Reactivation Request Form online today to ensure your participation is reactivated promptly.