If you want to become a GAP provider you will need to complete the application below. All completed applications will need to be emailed to firstname.lastname@example.org. Any applications not emailed will be rejected and sent back to the sender. When mailing the fee, please attach a hard copy of the application to the check. Applications will not be processed until payment is received.
NOTE: Form filings must be filed 30 days prior to use. Form filings must be submitted at the same time as the provider application. Please see the Rate and Form Filing section for form filing instructions. Please make sure that you have reviewed Title 31A-6b for compliance.