Join Our Network

* indicates a required field

Name

First Name: *

MI:

Last Name: *

Suffix:

Email: *

Practice Information

Are you a solo practitioner?
YesNo*

Are you part of a group practice (with a shared Tax ID)?
YesNo*

If so, please provide group name:

Office Location

Office Address: *

City: *

State: *

Zip: *

Telephone: (with area code)*

Fax:

County:

Do you practice at more than one location? YesNo

If so, please provide the address(s) and telephone of your other practice locations:

Information

REMINDER TO PROVIDERS: Any provider interested in applying for CBH participation must have (or apply for) a Georgia Medicaid number.

You must first attempt to apply on the State website. If you experience problems applying on the website, you may call the Provider Information Line at 1-800-766-4456.

If you need additional assistance, please call the CBH Provider Relations Department at 1-800-947-0633.

Medicaid Number:

Provider Type:

Board Certification: (MD's only)

Unique Qualifications: