Welcome to BlueCross BlueShield of Georgia

New Provider Application Form

The New Provider Application Form should be used by Georgia physicians, providers and professionals to submit a request to join the networks for Blue Cross and Blue Shield of Georgia (BCBSGa).

Complete the CREDENTIALED PROVIDER section of this form if you have a completed up-to-date credentialing application with CAQH and require credentialing by BCBSGa. Click here to see a list of providers who require credentialing.

Complete the ANCILLARY PROVIDER section of the form if you are a lab, ground or air ambulance, hearing aid distributor, durable medical equipment, home IV, immunization clinic, orthotic and prosthetic, cardiac event monitoring, and medical specialty pharmacy. Before completing the application form, click here for important information about closed networks.

NON-CREDENTIALED PROVIDERS such as mid-levels (NPs, PAs, midwives, etc) and hospital based (anesthesia, pathology, radiology, emergency room, and hospitalists) should complete this section of the form. For a complete list of non-credentialed provider types click here.

What Happens Next

The BCBSGa Network Relations Department will review your request, determine whether credentialing is required and send the appropriate Agreement Packet to the "contact /submitter details email address" indicated on your form. If there is no email address, please allow 2 weeks for mail delivery to the primary office mail address you provide below in this application form.

Please refrain from seeing BCBSGa members as an in-network provider until you have received notification of your network status.

Provider 

  • Credentialed Providers

    Complete the CREDENTIALED PROVIDER section of this form if you have a completed up-to-date credentialing application with CAQH and require credentialing by BCBSGa. Click here to see a list of providers who require credentialing.

    Provider information










    (behavioral health providers only)
    (behavioral health providers only)
    (If yes, STOP and complete the form section titled Non - Credentialed providers )










    Medicare/Medicaid participation



    Primary practice office












    Correspondence Address







    Contact/Submitter (person submitting the form)




  • Ancillary providers

    Complete this section if you one of these provider types: lab, ground or air ambulance, hearing aid distributor, durable medical equipment, home IV, immunization clinic, orthotic and prosthetic, cardiac event monitoring, or medical specialty pharmacy. Before completing form, click here for important information about closed networks.

    If not this provider type, go to the form section for NON CREDENTIALED PROVIDERS.

    Provider information
















    (Please indicate 'all', or list specific counties you will serve)






    Office Hours













    Identification numbers










    Payment/Remittance address







    Correspondence Address







    Licensure



    Governmental Program

    Contact/Submitter (person submitting form)




  • Non-Credentialed Providers

    NON-CREDENTIALED PROVIDERS such as mid-levels (NPs, PAs, midwives, etc) and hospital based (anesthesia, pathology, radiology, emergency room, and hospitalists) should complete this section of the form. For a complete list of non-credentialed provider types click here

    Provider information














    Provider Type/Specialty









    Medical license



    DEA registration



    Medicare/Medicaid participation



    Internship or residency




    Area(s) of expertise (behavioral health providers only)



    Primary practice information


















    Office Hours













    Additional information









    Correspondence Address
























    Contact/Submitter (person submitting form)




By clicking on the tab marked "SUBMIT" below, I agree as a condition of practicing in Georgia, to be subject to the jurisdiction and disciplinary authority of the appropriate agency. In addition, I hereby request the above changes and certify that the foregoing information is true and correct and that I am the named professional or am otherwise authorized to make this request and certification on behalf of the named professional.

To submit form ensure any sections that are not being populated are collapsed/closed.