Enrollment Information

Enrollment Application

Enrollment Application Instructions for Peach State Health Plan Advantage (HMO SNP)

Step 1: Please fill out all 6 pages of the application.

Step 2: Check appropriate YES/NO box for items 1 thru 5 on pages 2 and 3.

Step 3: Enter Primary Care Physician’s Name

Step 4: Sign and date the enrollment application for Advantage by Peach State Health Plan on page 5.

Step 5: Check any box on page 6 that applies to you.

Step 6: Mail the original copy to:

Peach State Health Plan Advantage

1100 Circle 75 Parkway

Suite 1100

Atlanta, GA 30339

If you have any questions regarding this application, please contact Member Services at the number listed below and ask to speak to a licensed insurance agent.

You are not required to speak with a sales agent. You can speak with a Member Service representative to receive plan information.

Member Services 1-877-725-7748 (TTY/TDD 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m.

Last Updated: 12182014
H7173_2015WEBSITE_Approved_12182014