Get Ga Pshp Facility And Ancillary Credentialing Application 2001-2025

Filling out the GA PSHP Facility And Ancillary Credentialing Application online is a crucial process for health care facilities seeking to ensure compliance with state regulations. This guide will walk you through each section of the application to facilitate the submission of necessary information efficiently.

Follow the steps to complete your application online:

1. Press the ‘Get Form’ button to acquire the application form and open it in your preferred editor.
2. Begin by entering the provider demographic information in section A. Include your facility or group name, professional category, address, phone number, fax number, email, hours of operation, federal tax ID number, and any relevant Medicaid or Medicare provider numbers.
3. Ensure to attach the required documents listed at the top of the application. This includes copies of your Georgia state license, quality improvement plan, other applicable state or federal licensures, accreditation or certification documents, current general liability coverage, and Medicare/Medicaid certification.
4. In section B, list all current and past licenses with the corresponding state, license number, date issued, expiration date, and type of licensure. Be thorough, as completeness is key.
5. Answer the questions provided in sections B and C regarding any limitations or issues with your facility license. If you answer 'Yes' to any questions, prepare to provide detailed explanations on a separate sheet.
6. In section D, fill out the requirements pertaining to laboratories if applicable, including your CLIA certification status.
7. Complete section E by providing the name of your insurance company, policy number, and amounts of coverage including specific and aggregate amounts.
8. Finally, in the release of information and attestation section, ensure you read the agreement fully, sign, date, and print your name to affirm the truthfulness of the information provided.

Complete your GA PSHP Facility And Ancillary Credentialing Application online today!