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September 28, 2022

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Application for New Participant

Application for New Participant
File Size:
2.69 MB
07 April 2015
468 x

This is the application form an individual must complete to become a participant in the Georgia Professionals Health Program. Please note that completing this application does not constitute membership in the Georgia PHP. You must meet with the PHP and have records reviewed before we can determine if you can be covered by our services. 

This form must be completed and all records should be in our hands before we meet with you. Call or email us with any questions.

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