Appendix F - Forms Table of Contents | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Table of Contents

Effective Date:

N/A

Chapter:

Appendix F

Policy Number:

Appendix F

Previous Policy Number(s):

Updated or Reviewed in MT:

MT-73

Policy Statement

Only State Office approved forms may be used.

Voter Registration Application Form Information

For a copy of the Voter Registration Application Form and information on how to apply to register to vote, visit: sos.ga.gov/sites/default/files/forms/GA_VR_APP_2019.pdf Also, refer to Form # VRA-95.

Medicaid Forms Table of Contents

Form Number	Form Title	Revision Date	Order Info	Owner
1	OSAH-1-Medicaid (Hearing Request)	07/23	Screen Print	OSAH
1	PeachCare for Kids Flyer (English)		Gainwell	DCH
6	LOC Approval/NH		Gainwell	DCH
6A	Physician’s Recommendation for Pediatric Care	08/24	Screen Print	DCH
21	PeachCare for Kids Handbook		Gainwell	DCH
41	PeachCare for Kids Handbook (Spanish)		Gainwell	DCH
59	Authorization for NH Facility Reimbursement/Vendor Payment		Gainwell	DCH
71	Medicaid Disability Determination Inquiry (Obsolete as of 09/2013)	02/11	Screen Print	DHS
89	Medicare Savings Programs Request for Information	08/24	Screen Print	DHS
94	Medicaid Application	10/22	SO	DHS
94 LP	Medicaid Application (Large Print)	01/22	SO	DHS
94 SP	Medicaid Application (Spanish)	10/22	SO	DHS
94 LP SP	Medicaid Application (Large Print Spanish)	01/22	SO	DHS
94A	Medicaid Streamlined Application	07/23	SO	DHS
94A LP	Medicaid Streamlined Application (Large Print)	01/22	SO	DHS
94A SP	Medicaid Streamlined Application (Spanish)	10/22	SO	DHS
94A LP SP	Medicaid Streamlined Application (Large Print Spanish)	01/22	SO	DHS
94A Appendix A	Streamlined Application Appendix A	07/23	SO	DHS
94A Appendix A SP	Streamlined Application Appendix A (Spanish)	09/17	SO	DHS
94A Appendix A LP	Streamlined Application Appendix A (Large Print)	09/17	SO	DHS
94A Appendix A SP LP	Streamlined Application Appendix A (Spanish Large Print)	09/17	SO	DHS
94A Appendix B	Streamlined Application Appendix B	07/23	S0	DHS
94A Appendix B SP	Streamlined Application Appendix B (Spanish)	09/17	SO	DHS
94A Appendix B LP	Streamlined Application Appendix B (Large Print)	09/17	SO	DHS
94A Appendix B SP LP	Streamlined Application Appendix B (Spanish Large Print)	09/17	SO	DHS
94A Appendix C	Streamlined Application Appendix C	07/23	SO	DHS
94A Appendix C SP	Streamlined Application Appendix C (Spanish)	04/22	SO	DHS
94A Appendix C LP	Streamlined Application Appendix C (Large Print)	09/17	SO	DHS
94A Appendix C SP LP	Streamlined Application Appendix C (Spanish Large Print)	09/17	SO	DHS
94A Appendix D	Streamlined Application Appendix D	07/23	SO	DHS
106	Insurance Clearance	06/24	Screen Print	DHS
107	SSI Status Change	06/24	Screen Print	DHS
109	SSI Cont Med Determination Notice (Ex Parte Cover Letter)	06/24	Screen Print	DHS
109 SP	SSI Cont Med Determination Notice (Ex Parte Cover Letter) (Spanish)	06/24	Screen Print	DHS
118	Request for Hearing	01/22	Screen Print	DHS
118 SP	Request for Hearing (Spanish)	02/10	Screen Print	DHS
123	Interagency/Interoffice Update and Follow-Up		Forms OL	DHS
124	Application for Health Insurance Premium Payments	11/22	Screen print	DCH
124I	Instructions: Application for Health Insurance Premium Payments	11/21	Screen Print	DCH
125	CHIPPRA Application	05/23	Screen Print	DCH
129	Recipient Notice for Spousal Impoverishment	06/24	Screen Print	DHS
130	TANF and Family Medicaid Child and Medical Support Letter	06/16	Screen Print	DHS
130 SP	TANF and Family Medicaid Child and Medical Support Letter (Spanish)	06/16	Screen Print	DHS
136	County Request for Final Appeal	02/10	Screen Print	DHS
138	Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate with DCSS	6/16	Screen Print	DHS
138 SP	Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate with DCSS (Spanish)	6/16	Screen Print	DHS
139	Contribution Statement	02/10	Screen Print	DHS
139 SP	Contribution Statement (Spanish)	02/10	Screen Print	DHS
171	Parent to Child Deeming Worksheet	10/12	Screen Print	DHS
172	ABD MAO Individual/Couple/Spouse to Spouse Deeming	10/12	SO	DHS
172I	Instructions: ABD MAO Individual/Couple/Spouse to Spouse Deeming		Screen Print	DHS
173	Verification Checklist	06/10	Screen Print	DHS
173 SP	Verification Checklist (Spanish)	06/10	Screen Print	DHS
173I	Instructions: Verification Checklist		Screen Print	DHS
174	SMEU Medical Records Cover Letter	06/24	Screen Print	DHS
184	SMEU Data Report	06/24	SO	DHS
185	Affidavit of Paternity	10/12	SO	DHS
214	Medicaid Notification Form	08/24	SO	DHS
214 SP	Medicaid Notification Form (Spanish)	11/07	SO	DHS
216	Declaration of Citizenship	06/24	Screen Print	DHS
216 SP	Declaration of Citizenship (Spanish)	06/24	Screen Print	DHS
217	Affidavit to Establish Identity for Medicaid Applicant/Recipients < 16	06/24	SO	DHS
217 SP	Affidavit to Establish Identity for Medicaid Applicant/Recipients < 16 (Spanish)	06/24	SO	DHS
218	Citizenship/Identity Verification Checklist	06/24	Screen Print	DHS
218 SP	Citizenship/Identity Verification Checklist (Spanish)	01/14	Screen Print	DHS
219	Affidavit of Facts Concerning Citizenship	06/24	Screen Print	DHS
219I	Instructions: Affidavit of Facts Concerning Citizenship			DHS
219 SP	Affidavit of Facts Concerning Citizenship (Spanish)	06/24	Screen Print	DHS
223	Medicaid and IV-E Application for Foster Care	10/12	Screen Print	DHS
223I	Instructions:Medicaid and IV-E Application for Foster Care		Screen Print	DHS
224	Removal Home Income and Asset Checklist	10/12	Screen Print	DHS
224I	Instructions:Removal Home Income and Asset Checklist		Screen Print	DHS]
225	IV-E Eligibility Documentation Sheet	10/12	Screen Print	DHS
226	Medicaid and IV-E Redetermination Form	10/12	Screen Print	DHS
226I	Instructions:Medicaid and IV-E Redetermination Form	10/12	Screen Print	DHS
227	Notification of Change in Foster Care or Adoption Assistance	10/12	Screen Print	DHS
227I	Instructions:Notification of Change in Foster Care or Adoption Assistance	10/12	Screen Print	DHS
238	Medically Needy Budget Sheet	08/11	SO	DHS
239M	MAGI Budget Sheet	04/23	Screen Print	DHS
243	Providing Verification of Citizenship for Medicaid	05/08	Screen Print	DHS
243 SP	Providing Verification of Citizenship for Medicaid (Spanish)	05/08	Screen Print	DHS
245	SMEU Request Form	06/24	SO	DHS
256	Interview Guide for TANF/FS/Medicaid		SO	DHS
285	Third Party Liability	01/06	Gainwell	DCH
297	Application for TANF Food Stamps or Medical Assistance. For voter registration information refer to Voter Registration Application Form Information	07/23	SO	DHS
297	Application for TANF Food Stamps or Medical Assistance (Arabic Chinese Farsi Hmong Italian Portuguese Russian or Vietnamese)		Hard Copy Only	DHS
297 SP	Application for TANF Food Stamps or Medical Assistance (Spanish) For voter registration information refer to Voter Registration Application Form Information	10/22	SO	DHS
297 LP	Application for TANF Food Stamps or Medical Assistance (Large Print). For voter registration information refer to Voter Registration Application Form Information	12/21	SO	DHS
297 SPLP	Application for TANF Food Stamps or Medical Assistance (Spanish Large Print). For voter registration information refer to Voter Registration Application Form Information	12/21	SO	DHS
297A	Rights and Responsibilities	10/22	SO	DHS
297A	Rights and Responsibilities		Hard Copy Only	DHS
297A SP	Rights and Responsibilities (Spanish)	10/22 (Spanish)]	SO	DHS
297A LP	Rights and Responsibilities (Large Print)	12/21	SO	DHS
297A SPLP	Rights and Responsibilities (Spanish Large Print)	12/21	SO	DHS
297M	Medicaid Addendum to Form 297 (Obsolete as of 12/2021)	01/14	SO	DHS
297M SP	Medicaid Addendum to Form 297 (Spanish) (Obsolete as of 12/2021)	01/14	SO	DHS
306	Annuity Issuer Notification	08/24	Screen Print	DHS
315	Official Notice of Georgia Medicaid Estate Recovery Program	10/21	Screen Print	DCH
315 SP	Official Notice of Georgia Medicaid Estate Recovery Program (Spanish)	10/21	Screen Print	DCH
315 LP	Official Notice of Georgia Medicaid Estate Recovery Program (Large Print)	10/21	Screen Print	DCH
315 SPLP	Official Notice of Georgia Medicaid Estate Recovery Program (Spanish Large Print)	10/21	Screen Print	DCH
327	Estate Recovery Notification Form	07/22	Screen Print	DCH
328	Quarterly Report Form	06/24	Screen Print	DHS
328 SP	Quarterly Report Form (Spanish)	06/24	Screen Print	DHS
400	Medically Needy First Day Liability Authorization for Reimbursement	4/93	Hard Copy Only	DCH
403	Adoption Assistance Benefits Memorandum	05/11	Screen Print	Adoptions
411	Undue Hardship Waiver Application	06/24	Screen Print	DHS
411 SP	Undue Hardship Waiver Application (Spanish)	06/24	Screen Print	DHS
508	Food Stamp TANF Medicaid Renewal Form.For voter registration information refer Voter Registration Application Form Information	10/22	SO	DHS
508 SP	Food Stamp TANF Medicaid Renewal Form. For voter registration information refer to Voter Registration Application Form Information	10/22 (Spanish)	SO	DHS
508 LP	Food Stamp TANF Medicaid Renewal Form (Large Print). For voter registration information refer to Voter Registration Application Form Information	12/21	SO	DHS
508 SPLP	Food Stamp TANF Medicaid Renewal Form (Spanish Large Print). For voter registration information refer to Voter Registration Application Form Information	12/21	SO	DHS
512	Notification of Eligibility-EMA	06/24	Screen Print	DHS
512 SP	Notification of Eligibility-EMA (Spanish)	06/24	Screen Print	DHS
526	Physician’s Statement for EMA	08/24	Screen Print	DCH
700	Application for Medicaid & Medicare Savings for Qualified Beneficiaries	10/22	SO	DHS
700 SP	Application for Medicaid & Medicare Savings for Qualified Beneficiaries (Spanish)	10/22	SO	DHS
700 LP	Application for Medicaid & Medicare Savings for Qualified Beneficiaries (Large Print)	01/22	SO	DHS
700 SPLP	Application for Medicaid & Medicare Savings for Qualified Beneficiaries (Spanish Large Print)	01/22	SO	DHS
701	Q-Track Brochure	08/24	SO	DHS
703	Medicare Buy-In Problem Template	06/24	Screen Print	DHS
704	TEFRA/Katie Beckett Cost Effectiveness Form	10/04	Screen Print	DCH
705	TEFRA/Katie Beckett LOC Determination Routing Form	05/12	Screen Print	DCH
706	TEFRA/Katie Beckett Medical Necessity LOC Statement	01/18	Screen Print	DCH
713	Interagency Interoffice referral/ Follow Up	11/10	SO	DHS
809	Verification of Earned Income	06/16	SO	DHS
809 SP	Verification of Earned Income (Spanish)	06/16	SO	DHS
936	QIT Certification	06/24	Screen Print	DCH
937	QIT Review Letter	06/24	Screen Print	DHS
937 SP	QIT Review Letter (Spanish)	06/24	Screen Print	DHS
938	Understanding Medicaid (Spanish)		Gainwell	DCH
939	Understanding Medicaid		Gainwell	DCH
942	IME Verification Form	08/24	Screen Print	DHS
943	Notification of Deduction of Medical Expense	06/24	Screen Print	DHS
944	IME Query Form	06/24	Screen Print	DCH
945	QIT Trustee Guide	06/24	Screen Print	DCH
945 SP	QIT Trustee Guide (Spanish)	06/24	Screen Print	DCH
946	QIT Frequently Asked Questions and Worksheet	06/24	Screen Print	DCH
946 SP	QIT Frequently Asked Questions and Worksheet (Spanish)	06/24	Screen Print	DCH
947	QIT Approved Format Deviation	08/24	Screen Print	DHS
948	QIT Approved Template 1	08/24	Screen Print	DCH
949	QIT Checklist	08/24	Screen Print	DCH
950	Facility Action Request	10/12	Screen Print	DHS
954	OptumRx Prescription Update Template	06/24	Screen Print	DHS
955	Notice of Review of Promissory Note Loan or Property Agreement	06/24	Screen Print	DHS
955 SP	Notice of Review of Promissory Note Loan or Property Agreement (Spanish)	06/24	Screen Print	DHS
956	Special Needs Trust Routing Form	08/24	Screen Print	DHS
958	Nursing Facility Information Request	06/24	Screen Print	DHS
960	IME Pricing Document	08/24	Screen Print	DCH
962	Certification of Medicaid Eligibility	07/23	SO	DHS
963	Medicaid Notification Form	01/07	SO	DHS
963I	Instructions: Medicaid Notification Form			DHS
966	Absent Parent Information Form	08/24	Screen Print	DHS
967	Non-Emergency Medical Transportation Information Sheet (NEMT)	08/24	Screen Print	DCH
967 SP	Non-Emergency Transportation Broker Sheet (Spanish)		Screen Print	DCH
968	MN PL Budget Sheet	10/12	Screen Print	DHS
969	Living Arrangement Determination - LA/ISM Guide	10/12	Screen Print	DHS
970	VA Communication Form	08/24	SO	DHS
984	Burial Contract Verification	07/24	Screen Print	DHS
985	Burial Exclusion and Designation	08/24	Screen Print	DHS
986	MAO Cemetery Lot Verification	08/24	Screen Print	DHS
987	Designation of Cemetery Lot	08/24	Screen Print	DHS
988	Notice of Review of Annuity	06/24	Screen Print	DCH
988 SP	Notice of Review of Annuity (Spanish)	06/24	Screen Print	DCH
991	MAO Property Search Record	08/24	SO	DHS
995	Pathways Qualifying Activities Report Form	07/23	Screen Print	DHS
996	Pathways Good Cause RM and RA Form	07/23	Screen Print	DHS
998	Notice of Termination of Medicaid Benefits Due to Contract(s)	08/24	Screen Print	DHS
1610-U2	Public Assistance Agency Information	02/82	SSA	Social Security
3327	Health Check Brochure	10/22	Gainwell	DCH
3328	Health Check Brochure (Spanish)		Gainwell	DCH
3329	Health Check Brochure (Braille)		Gainwell	DCH
5459	Authorization for Release of Information	07/16	SO	DHS
5459 SP	Authorization for Release of Information (Spanish)	07/16	SO	DHS
5460	Notice of Privacy Practices	12/23	Screen Print	DHS
5460 SP	Notice of Privacy Practices (Spanish)	12/23	Screen Print	DHS
	Notice of Privacy Practices (Arabic Chinese Farsi Hmong Italian Portuguese Russian Vietnamese)		Hard Copy Only	DHS
G-845-S	INS SAVE Document Verification		DHS	INS
SS-5	Application for a Social Security Card		SSA	Social Security
	Foster Care Worker Card	04/04	Screen Print	DHS
	GMWD Fact Sheet	09/17	Screen Print	DHS
	ICAMA Member Contact List		NA	DHS
	ICAMA Non-Member Contact List			DHS
	IV-E Budget Sheet	10/12	Screen Print	DHS
	Letter of Non-Cooperation with DCSS	10/12	Screen Print	DHS
	Level of Care Agreement		NA	DBHDD
	Medicaid Review Response Form	05/16	Screen Print	DHS
	Medically Needy Option Statement	05/15	Screen Print	DHS
	(Medicare) Part D Complaint Checklist		Screen Print	CMS
	PeachCare Special Request Form		Screen Print	DCH
	Record of Life Insurance Policies	01/07	Screen Print	DHS
	TEFRA/Katie Beckett Cover Letter	05/12	Screen Print	DHS
	TEFRA/Katie Beckett Cover Letter (Spanish)	04/05	Screen Print	DHS
	TEFRA/Katie Beckett Worksheet	08/11	Screen Print	DHS
	Undue Hardship Waiver Letter	02/07	Screen Print	DHS
	Women’s Health Medicaid Physician’s Statement of Treatment	09/23	Screen Print	DHS
	Women’s Health Medicaid Physician’s Statement of Treatment (Spanish)	04/23	Screen Print	DHS
	Women’s Health Medicaid Review Form (Obsolete as of 21/2022)	01/14	Screen Print	DHS

Form Number

Form Title

Revision Date

Order Info

Owner

OSAH-1-Medicaid (Hearing Request)

07/23

Screen Print

OSAH

PeachCare for Kids Flyer (English)

Gainwell

DCH

LOC Approval/NH

Gainwell

DCH

Physician’s Recommendation for Pediatric Care

08/24

Screen Print

DCH

PeachCare for Kids Handbook

Gainwell

DCH

PeachCare for Kids Handbook (Spanish)

Gainwell

DCH

Authorization for NH Facility Reimbursement/Vendor Payment

Gainwell

DCH

Medicaid Disability Determination Inquiry (Obsolete as of 09/2013)

02/11

Screen Print

DHS

Medicare Savings Programs Request for Information

08/24

Screen Print

DHS

Medicaid Application

10/22

DHS

94 LP

Medicaid Application (Large Print)

01/22

DHS

94 SP

Medicaid Application (Spanish)

10/22

DHS

94 LP SP

Medicaid Application (Large Print Spanish)

01/22

DHS

94A

Medicaid Streamlined Application

07/23

DHS

94A LP

Medicaid Streamlined Application (Large Print)

01/22

DHS

94A SP

Medicaid Streamlined Application (Spanish)

10/22

DHS

94A LP SP

Medicaid Streamlined Application (Large Print Spanish)

01/22

DHS

94A Appendix A

Streamlined Application Appendix A

07/23

DHS

94A Appendix A SP

Streamlined Application Appendix A (Spanish)

09/17

DHS

94A Appendix A LP

Streamlined Application Appendix A (Large Print)

09/17

DHS

94A Appendix A SP LP

Streamlined Application Appendix A (Spanish Large Print)

09/17

DHS

94A Appendix B

Streamlined Application Appendix B

07/23

DHS

94A Appendix B SP

Streamlined Application Appendix B (Spanish)

09/17

DHS

94A Appendix B LP

Streamlined Application Appendix B (Large Print)

09/17

DHS

94A Appendix B SP LP

Streamlined Application Appendix B (Spanish Large Print)

09/17

DHS

94A Appendix C

Streamlined Application Appendix C

07/23

DHS

94A Appendix C SP

Streamlined Application Appendix C (Spanish)

04/22

DHS

94A Appendix C LP

Streamlined Application Appendix C (Large Print)

09/17

DHS

94A Appendix C SP LP

Streamlined Application Appendix C (Spanish Large Print)

09/17

DHS

94A Appendix D

Streamlined Application Appendix D

07/23

DHS

106

Insurance Clearance

06/24

Screen Print

DHS

107

SSI Status Change

06/24

Screen Print

DHS

109

SSI Cont Med Determination Notice (Ex Parte Cover Letter)

06/24

Screen Print

DHS

109 SP

SSI Cont Med Determination Notice (Ex Parte Cover Letter) (Spanish)

06/24

Screen Print

DHS

118

Request for Hearing

01/22

Screen Print

DHS

118 SP

Request for Hearing (Spanish)

02/10

Screen Print

DHS

123

Interagency/Interoffice Update and Follow-Up

Forms OL

DHS

124

Application for Health Insurance Premium Payments

11/22

Screen print

DCH

124I

Instructions: Application for Health Insurance Premium Payments

11/21

Screen Print

DCH

125

CHIPPRA Application

05/23

Screen Print

DCH

129

Recipient Notice for Spousal Impoverishment

06/24

Screen Print

DHS

130

TANF and Family Medicaid Child and Medical Support Letter

06/16

Screen Print

DHS

130 SP

TANF and Family Medicaid Child and Medical Support Letter (Spanish)

06/16

Screen Print

DHS

136

County Request for Final Appeal

02/10

Screen Print

DHS

138

Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate with DCSS

6/16

Screen Print

DHS

138 SP

Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate with DCSS (Spanish)

6/16

Screen Print

DHS

139

Contribution Statement

02/10

Screen Print

DHS

139 SP

Contribution Statement (Spanish)

02/10

Screen Print

DHS

171

Parent to Child Deeming Worksheet

10/12

Screen Print

DHS

172

ABD MAO Individual/Couple/Spouse to Spouse Deeming

10/12

DHS

172I

Instructions: ABD MAO Individual/Couple/Spouse to Spouse Deeming

Screen Print

DHS

173

Verification Checklist

06/10

Screen Print

DHS

173 SP

Verification Checklist (Spanish)

06/10

Screen Print

DHS

173I

Instructions: Verification Checklist

Screen Print

DHS

174

SMEU Medical Records Cover Letter

06/24

Screen Print

DHS

184

SMEU Data Report

06/24

DHS

185

Affidavit of Paternity

10/12

DHS

214

Medicaid Notification Form

08/24

DHS

214 SP

Medicaid Notification Form (Spanish)

11/07

DHS

216

Declaration of Citizenship

06/24

Screen Print

DHS

216 SP

Declaration of Citizenship (Spanish)

06/24

Screen Print

DHS

217

Affidavit to Establish Identity for Medicaid Applicant/Recipients < 16

06/24

DHS

217 SP

Affidavit to Establish Identity for Medicaid Applicant/Recipients < 16 (Spanish)

06/24

DHS

218

Citizenship/Identity Verification Checklist

06/24

Screen Print

DHS

218 SP

Citizenship/Identity Verification Checklist (Spanish)

01/14

Screen Print

DHS

219

Affidavit of Facts Concerning Citizenship

06/24

Screen Print

DHS

219I

Instructions: Affidavit of Facts Concerning Citizenship

DHS

219 SP

Affidavit of Facts Concerning Citizenship (Spanish)

06/24

Screen Print

DHS

223

Medicaid and IV-E Application for Foster Care

10/12

Screen Print

DHS

223I

Instructions:Medicaid and IV-E Application for Foster Care

Screen Print

DHS

224

Removal Home Income and Asset Checklist

10/12

Screen Print

DHS

224I

Instructions:Removal Home Income and Asset Checklist

Screen Print

DHS]

225

IV-E Eligibility Documentation Sheet

10/12

Screen Print

DHS

226

Medicaid and IV-E Redetermination Form

10/12

Screen Print

DHS

226I

Instructions:Medicaid and IV-E Redetermination Form

10/12

Screen Print

DHS

227

Notification of Change in Foster Care or Adoption Assistance

10/12

Screen Print

DHS

227I

Instructions:Notification of Change in Foster Care or Adoption Assistance

10/12

Screen Print

DHS

238

Medically Needy Budget Sheet

08/11

DHS

239M

MAGI Budget Sheet

04/23

Screen Print

DHS

243

Providing Verification of Citizenship for Medicaid

05/08

Screen Print

DHS

243 SP

Providing Verification of Citizenship for Medicaid (Spanish)

05/08

Screen Print

DHS

245

SMEU Request Form

06/24

DHS

256

Interview Guide for TANF/FS/Medicaid

DHS

285

Third Party Liability

01/06

Gainwell

DCH

297

Application for TANF Food Stamps or Medical Assistance. For voter registration information refer to Voter Registration Application Form Information

07/23

DHS

297

Application for TANF Food Stamps or Medical Assistance (Arabic Chinese Farsi Hmong Italian Portuguese Russian or Vietnamese)

Hard Copy Only

DHS

297 SP

Application for TANF Food Stamps or Medical Assistance (Spanish) For voter registration information refer to Voter Registration Application Form Information

10/22

DHS

297 LP

Application for TANF Food Stamps or Medical Assistance (Large Print). For voter registration information refer to Voter Registration Application Form Information

12/21

DHS

297 SPLP

Application for TANF Food Stamps or Medical Assistance (Spanish Large Print). For voter registration information refer to Voter Registration Application Form Information

12/21

DHS

297A

Rights and Responsibilities

10/22

DHS

297A

Rights and Responsibilities

Hard Copy Only

DHS

297A SP

Rights and Responsibilities (Spanish)

10/22 (Spanish)]

DHS

297A LP

Rights and Responsibilities (Large Print)

12/21

DHS

297A SPLP

Rights and Responsibilities (Spanish Large Print)

12/21

DHS

297M

Medicaid Addendum to Form 297 (Obsolete as of 12/2021)

01/14

DHS

297M SP

Medicaid Addendum to Form 297 (Spanish) (Obsolete as of 12/2021)

01/14

DHS

306

Annuity Issuer Notification

08/24

Screen Print

DHS

315

Official Notice of Georgia Medicaid Estate Recovery Program

10/21

Screen Print

DCH

315 SP

Official Notice of Georgia Medicaid Estate Recovery Program (Spanish)

10/21

Screen Print

DCH

315 LP

Official Notice of Georgia Medicaid Estate Recovery Program (Large Print)

10/21

Screen Print

DCH

315 SPLP

Official Notice of Georgia Medicaid Estate Recovery Program (Spanish Large Print)

10/21

Screen Print

DCH

327

Estate Recovery Notification Form

07/22

Screen Print

DCH

328

Quarterly Report Form

06/24

Screen Print

DHS

328 SP

Quarterly Report Form (Spanish)

06/24

Screen Print

DHS

400

Medically Needy First Day Liability Authorization for Reimbursement

4/93

Hard Copy Only

DCH

403

Adoption Assistance Benefits Memorandum

05/11

Screen Print

Adoptions

411

Undue Hardship Waiver Application

06/24

Screen Print

DHS

411 SP

Undue Hardship Waiver Application (Spanish)

06/24

Screen Print

DHS

508

Food Stamp TANF Medicaid Renewal Form.For voter registration information refer Voter Registration Application Form Information

10/22

DHS

508 SP

Food Stamp TANF Medicaid Renewal Form. For voter registration information refer to Voter Registration Application Form Information

10/22 (Spanish)

DHS

508 LP

Food Stamp TANF Medicaid Renewal Form (Large Print). For voter registration information refer to Voter Registration Application Form Information

12/21

DHS

508 SPLP

Food Stamp TANF Medicaid Renewal Form (Spanish Large Print). For voter registration information refer to Voter Registration Application Form Information

12/21

DHS

512

Notification of Eligibility-EMA

06/24

Screen Print

DHS

512 SP

Notification of Eligibility-EMA (Spanish)

06/24

Screen Print

DHS

526

Physician’s Statement for EMA

08/24

Screen Print

DCH

700

Application for Medicaid & Medicare Savings for Qualified Beneficiaries

10/22

DHS

700 SP

Application for Medicaid & Medicare Savings for Qualified Beneficiaries (Spanish)

10/22

DHS

700 LP

Application for Medicaid & Medicare Savings for Qualified Beneficiaries (Large Print)

01/22

DHS

700 SPLP

Application for Medicaid & Medicare Savings for Qualified Beneficiaries (Spanish Large Print)

01/22

DHS

701

Q-Track Brochure

08/24

DHS

703

Medicare Buy-In Problem Template

06/24

Screen Print

DHS

704

TEFRA/Katie Beckett Cost Effectiveness Form

10/04

Screen Print

DCH

705

TEFRA/Katie Beckett LOC Determination Routing Form

05/12

Screen Print

DCH

706

TEFRA/Katie Beckett Medical Necessity LOC Statement

01/18

Screen Print

DCH

713

Interagency Interoffice referral/ Follow Up

11/10

DHS

809

Verification of Earned Income

06/16

DHS

809 SP

Verification of Earned Income (Spanish)

06/16

DHS

936

QIT Certification

06/24

Screen Print

DCH

937

QIT Review Letter

06/24

Screen Print

DHS

937 SP

QIT Review Letter (Spanish)

06/24

Screen Print

DHS

938

Understanding Medicaid (Spanish)

Gainwell

DCH

939

Understanding Medicaid

Gainwell

DCH

942

IME Verification Form

08/24

Screen Print

DHS

943

Notification of Deduction of Medical Expense

06/24

Screen Print

DHS

944

IME Query Form

06/24

Screen Print

DCH

945

QIT Trustee Guide

06/24

Screen Print

DCH

945 SP

QIT Trustee Guide (Spanish)

06/24

Screen Print

DCH

946

QIT Frequently Asked Questions and Worksheet

06/24

Screen Print

DCH

946 SP

QIT Frequently Asked Questions and Worksheet (Spanish)

06/24

Screen Print

DCH

947

QIT Approved Format Deviation

08/24

Screen Print

DHS

948

QIT Approved Template 1

08/24

Screen Print

DCH

949

QIT Checklist

08/24

Screen Print

DCH

950

Facility Action Request

10/12

Screen Print

DHS

954

OptumRx Prescription Update Template

06/24

Screen Print

DHS

955

Notice of Review of Promissory Note Loan or Property Agreement

06/24

Screen Print

DHS

955 SP

Notice of Review of Promissory Note Loan or Property Agreement (Spanish)

06/24

Screen Print

DHS

956

Special Needs Trust Routing Form

08/24

Screen Print

DHS

958

Nursing Facility Information Request

06/24

Screen Print

DHS

960

IME Pricing Document

08/24

Screen Print

DCH

962

Certification of Medicaid Eligibility

07/23

DHS

963

Medicaid Notification Form

01/07

DHS

963I

Instructions: Medicaid Notification Form

DHS

966

Absent Parent Information Form

08/24

Screen Print

DHS

967

Non-Emergency Medical Transportation Information Sheet (NEMT)

08/24

Screen Print

DCH

967 SP

Non-Emergency Transportation Broker Sheet (Spanish)

Screen Print

DCH

968

MN PL Budget Sheet

10/12

Screen Print

DHS

969

Living Arrangement Determination - LA/ISM Guide

10/12

Screen Print

DHS

970

VA Communication Form

08/24

DHS

984

Burial Contract Verification

07/24

Screen Print

DHS

985

Burial Exclusion and Designation

08/24

Screen Print

DHS

986

MAO Cemetery Lot Verification

08/24

Screen Print

DHS

987

Designation of Cemetery Lot

08/24

Screen Print

DHS

988

Notice of Review of Annuity

06/24

Screen Print

DCH

988 SP

Notice of Review of Annuity (Spanish)

06/24

Screen Print

DCH

991

MAO Property Search Record

08/24

DHS

995

Pathways Qualifying Activities Report Form

07/23

Screen Print

DHS

996

Pathways Good Cause RM and RA Form

07/23

Screen Print

DHS

998

Notice of Termination of Medicaid Benefits Due to Contract(s)

08/24

Screen Print

DHS

1610-U2

Public Assistance Agency Information

02/82

SSA

Social Security

3327

Health Check Brochure

10/22

Gainwell

DCH

3328

Health Check Brochure (Spanish)

Gainwell

DCH

3329

Health Check Brochure (Braille)

Gainwell

DCH

5459

Authorization for Release of Information

07/16

DHS

5459 SP

Authorization for Release of Information (Spanish)

07/16

DHS

5460

Notice of Privacy Practices

12/23

Screen Print

DHS

5460 SP

Notice of Privacy Practices (Spanish)

12/23

Screen Print

DHS

Notice of Privacy Practices (Arabic Chinese Farsi Hmong Italian Portuguese Russian Vietnamese)

Hard Copy Only

DHS

G-845-S

INS SAVE Document Verification

DHS

INS

SS-5

Application for a Social Security Card

SSA

Social Security

Foster Care Worker Card

04/04

Screen Print

DHS

GMWD Fact Sheet

09/17

Screen Print

DHS

ICAMA Member Contact List

DHS

ICAMA Non-Member Contact List

DHS

IV-E Budget Sheet

10/12

Screen Print

DHS

Letter of Non-Cooperation with DCSS

10/12

Screen Print

DHS

Level of Care Agreement

DBHDD

Medicaid Review Response Form

05/16

Screen Print

DHS

Medically Needy Option Statement

05/15

Screen Print

DHS

(Medicare) Part D Complaint Checklist

Screen Print

CMS

PeachCare Special Request Form

Screen Print

DCH

Record of Life Insurance Policies

01/07

Screen Print

DHS

TEFRA/Katie Beckett Cover Letter

05/12

Screen Print

DHS

TEFRA/Katie Beckett Cover Letter (Spanish)

04/05

Screen Print

DHS

TEFRA/Katie Beckett Worksheet

08/11

Screen Print

DHS

Undue Hardship Waiver Letter

02/07

Screen Print

DHS

Women’s Health Medicaid Physician’s Statement of Treatment

09/23

Screen Print

DHS

Women’s Health Medicaid Physician’s Statement of Treatment (Spanish)

04/23

Screen Print

DHS

Women’s Health Medicaid Review Form (Obsolete as of 21/2022)

01/14

Screen Print

DHS