The Initial (Part One), the Reappointment (Part One), and the Georgia Association of Health Plans Part Two Forms have recently been revised pursuant to a number of suggestions from healthcare entities that accept and use the Forms.  The majority of the revisions are clerical or cosmetic, and are not substantive changes.  The revisions are designed to make the Forms more user-friendly and to eliminate inapplicable choices, such as “Does Not Apply”, where they were inappropriate.

The revisions were voted on and agreed to by the members of the Georgia UHPCAF Committee at its meeting on July 28, 2003.  The application Forms dated 7/28/03 do not invalidate Forms dated 8/22/02.  The decision to continue to accept the 2002 Forms will be entity-specific.

Initial Appointment

The initial application has been designed and organized into two main parts: Part One and Part Two.  In order for your application to be considered complete, you must submit Part One & Part Two simultaneously.

Part One is standardized for participating Hospitals, Health Plans and/or Healthcare Entities, and contains identical questions that Hospitals, Health Plans and/or Healthcare Entities need to ask as part of their credentialing process.

Part Two for Health Plans is standardized and contains additional identical questions that health plans need to ask as part of their credentialing processes.

Part Two for Hospitals contains additional, customized or more specific questions as part of their credentialing and privileging processes and should be obtained from the respective hospital.

Please Note: Once you have downloaded, opened and completed the forms, be sure to save the forms on your computer (if you complete the Microsoft WORD version) or make a photocopy (if you manually complete the form(s).  You will only need to complete this/these form(s) once and maintain the information contained therein as necessary.  You are responsible for providing current information at all times and to update substantial changes throughout the credentialing period. Please remember that you must sign and date a new attestation page each time your form is submitted and that in order for you application to be considered complete, you must submit Part One & Part Two simultaneously . The completed forms can be used for each initial application submitted to Hospitals, Health Plans and/or Healthcare Entities that require the use of the Georgia UHPCAF.

Reappointment for Hospitals & Health Plans

You will be contacted by the Hospital, Health Plan and/or other Healthcare Entity(ies) when it is time for your reappointment.

This Application Form for Reappointment has been designed and organized into two main parts: Part One and Part Two.

Part One is standardized for participating Hospitals, Health Plans and/or other Healthcare Entities and contains identical questions that Hospitals, Health Plans and/or other Healthcare Entities need to ask as a part of their credentialing processes for reappointment. Note: If using an electronic version of Part One, check your answers against the date of your last (re)appointment to the Healthcare Entity to which you are applying in order to ensure accuracy.

Part Two contains additional, customized or more specific questions that an individual Hospital, Health Plan and/or Healthcare Entity(ies) needs you to answer for your Application Form for Reappointment to be considered complete.  Each Hospital, Health Plan and/or Healthcare Entity(ies) will provide you with Part Two when notifying you that your Application Form for Reappointment is due.  In order for your application to be considered complete, you must submit Part One & Part Two simultaneously.

Please Note: Once you have downloaded, opened and completed Part One, be sure to save Part One on your computer (if you complete the Microsoft WORD version) or make a photocopy (if you manually complete the form).  You will only need to complete Part One once and maintain the information contained therein as necessary.  You are responsible for providing current information at all times and to update substantial changes throughout the credentialing period.  The completed Part One for Reappointment can be used for each re-appointment application submitted to  Healthcare Entities that require the use of the Georgia UHPCAF.

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