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E-Blast: ATTN Directors: FY19 Contract Requirements (reminder)

January 29, 2018 10:09 AM

Dear Providers:

As we approach the FY19 contract year, our goal is to ensure that all FY19 contracts are executed timely and efficiently.  To that end, we will need the documents below submitted to the Office of Provider Management by close of business on February 9, 2018.

All documents should be submitted electronically to Brenda Jones at or faxed to 678-747-6881.  If faxing, please include your organization's name, address and contact information on the cover page.  If you have questions or concerns, contact either Brenda Jones at or 404-232-7860 or LaShaunda Daniel at or 404-657-0919.

  • Georgia Secretary of State Corporations Divisions (Print document showing Active/Compliance for year 2017-
  • Corporate Resolution Letter (Not-for-Profit-Only)
  • Criminal Background Form
  • Security & Immigration Compliance Form
  • Tax Compliance Form
  • W-9
  • Vendor Management Form
  • Vendor-Provider Request Form (Each location)
  • Certificate of Liability Insurance (Send single page from insurance company)
    • Malpractice/Professional Liability Policy ($1 million per occurrence/$3 million aggregate policy limits)
    • Commercial General Liability Policy ($1 million per occurrence/$3 million dollar aggregate policy limits)
    • Business Auto Policy ($1 million per occurrence/$1 million dollar aggregate policy limits)
    • Commercial Umbrella Policy ($1 million and $3 million dollar policy limits)
    • Workers Compensation Insurance (if employs 3 or more employees)

A print copy of this memo is available here.

Thanks in advance,

Office of Provider Management