Enrollment Information

Enrollment Application

Enrollment Application Instructions for Advantage by Peach State Health Plan (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:

Advantage by Peach State Health Plan

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) 1-800-255-0056  7 days a week 8AM to 8PM.

Last Updated: 03/20/2014   H7173_2014Website_Approved_4/29/2014