Provider Forms

• Provider Request for Extended Repayment Plan - Posted 12/4/18 (PDF, 134.65 KB)
• Universal 17-P Auth Form - Posted 10/31/16 (PDF, 208.86 KB)
• Synagis Policy Statement RSV Season 2020-2021 - Posted 06/16/21 (PDF, 208.94 KB)
• Signed Repayment Plan Policy - Updated 03/27/15 (PDF, 445.56 KB)
• Georgia Watch Fax Form.pdf (PDF, 150.82 KB)
• FAQs – Medicaid Provider/Facility Application Fees – 06/12/14   (PDF, 77.09 KB)
• HS&R Report Request Form - Updated 9/27/17 (PDF, 38 KB)
• Provider Administered Drug Form (PDF, 272.49 KB)