Appendix F: Forms Table of Contents

Georgia State Seal

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Appendix F TOC: Forms

Effective Date:

June 2025

Chapter:

Appendix F

Policy Number:

Appendix F

Previous MT Number(s):

MT 74

Updated or Reviewed in MT:

MT 76

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 # Form Title Revision Date Alternate Versions Instruct- ions Order Info Owner

OSAH-1

OSAH-1-Medicaid (Hearing Request)

07/23

PAMMS

OSAH

6

Physician’s Recommendation Concerning Nursing Facility Care or Intermediate Care for the Intellectually Disabled

Gainwell

DCH

6A

Physician’s Recommendation for Pediatric Care

Gainwell

DCH

59

Authorization for NH Facility Reimbursement

Gainwell

DCH

71

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

02/11

DHS

89

Medicare Savings Programs Request for Information

08/24

PAMMS

DHS

94

Medicaid Application

04/24

LP SP SPLP

SO

DHS

94A

Medicaid Streamlined Application

05/25

LP SP SPLP

SO

DHS

94A Appendix A

Streamlined Application Appendix A

01/24

LP SP SPLP

SO

DHS

94A Appendix B

Streamlined Application Appendix B

07/23

LP SP SPLP

S0

DHS

94A Appendix C

Streamlined Application Appendix C

07/23

LP SP SPLP

SO

DHS

94A Appendix D

Streamlined Application Appendix D

06/24

LP SP SPLP

SO

DHS

106

Resource Clearance

05/25

PAMMS

DHS

107

SSI Status Change

06/24

PAMMS

DHS

109

SSI Cont Med Determination Notice (Ex Parte Cover Letter)

06/24

SP

PAMMS

DHS

118

Request for Hearing

01/22

SP

PAMMS

DHS

123

Interagency/Interoffice Update and Follow-Up

Forms OL

DHS

124

Application for Health Insurance Premium Payments

11/22

I

PAMMS

DCH

125

CHIPRA Application

05/23

PAMMS

DCH

129

Recipient Notice for Spousal Impoverishment

06/24

PAMMS

DHS

130

TANF and Family Medicaid Child and Medical Support Letter

06/16

SP

PAMMS

DHS

136

County Request for Final Appeal

12/24

PAMMS

DHS

138

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

12/24

SP

PAMMS

DHS

139

Contribution Statement

12/24

SP

PAMMS

DHS

171

Parent to Child Deeming Worksheet

10/12

PAMMS

DHS

172

ABD MAO Individual/Couple/Spouse to Spouse Deeming

10/12

I

SO

DHS

173

Verification Checklist

06/10

SP

I

PAMMS

DHS

174

SMEU Medical Records Cover Letter

06/24

PAMMS

DHS

184

SMEU Data Report

06/24

SO

DHS

185

Affidavit of Paternity

10/12

SO

DHS

214

Medicaid Notification Form

08/24

SP

SO

DHS

216

Declaration of Citizenship

06/24

SP

PAMMS

DHS

217

Affidavit to Establish Identity for Medicaid Applicant/Recipients < 16

06/24

SP

SO

DHS

218

Citizenship/Identity Verification Checklist

06/24

SP

PAMMS

DHS

219

Affidavit of Facts Concerning Citizenship

06/24

SP

I

PAMMS

DHS

223

Medicaid and IV-E Application for Foster Care

10/12

I

PAMMS

DHS

224

Removal Home Income and Asset Checklist

10/12

I

PAMMS

DHS

225

IV-E Eligibility Documentation Sheet

10/12

PAMMS

DHS

226

Medicaid and IV-E Redetermination Form

10/12

I

PAMMS

DHS

227

Notification of Change in Foster Care or Adoption Assistance

10/12

I

PAMMS

DHS

238

Medically Needy Budget Sheet

08/11

SO

DHS

239M

MAGI Budget Sheet

04/23

PAMMS

DHS

243

Providing Verification of Citizenship for Medicaid

05/08

SP

PAMMS

DHS

245

SMEU Request Form

06/24

SO

DHS

252

Letter of Non-Cooperation with DCSS

05/25

PAMMS

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

10/24

SP LP SPLP

SO

DHS

297

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

Hard Copy Only

DHS

297A

Rights and Responsibilities

10/24

LP SP SPLP

SO

DHS

297A

Rights and Responsibilities (Arabic Chinese Farsi Hmong Italian Portuguese Russian or Vietnamese)

Hard Copy Only

DHS

297M

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

01/14

SO

DHS

306

Annuity Issuer Notification

08/24

PAMMS

DHS

315

Official Notice of Georgia Medicaid Estate Recovery Program

10/21

SP LP SPLP

PAMMS

DCH

326

Medically Needy Option Statement

12/24

PAMMS

DCH

327

Estate Recovery Notification Form

07/22

PAMMS

DCH

328

Quarterly Report Form

06/24

SP

PAMMS

DHS

400

Medically Needy First Day Liability Authorization for Reimbursement

05/25

Hard Copy Only

DCH

411

Undue Hardship Waiver Application

06/24

SP

Screen Print

DHS

412

Undue Hardship Waiver Letter

12/24

PAMMS

DHS

508

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

10/24

LP SP SPLP

SO

DHS

512

Notification of Eligibility-EMA

06/24

SP

PAMMS

DHS

526

Physician’s Statement for EMA

08/24

PAMMS

DCH

700

Application for Medicaid & Medicare Savings for Qualified Beneficiaries

10/22

LP SP SPLP

SO

DHS

701

Q-Track Brochure

08/24

SP

SO

DHS

703

Medicare Buy-In Problem Template

06/24

PAMMS

DHS

704

TEFRA/Katie Beckett Cost Effectiveness Form

10/04

PAMMS

DCH

705

TEFRA/Katie Beckett LOC Determination Routing Form

01/25

PAMMS

DCH

706

TEFRA/Katie Beckett Medical Necessity LOC Statement

05/25

PAMMS

DCH

713

Interagency Interoffice Referral/ Follow Up

11/10

SO

DHS

809

Verification of Earned Income

12/24

SP

SO

DHS

936

QIT Certification

06/24

PAMMS

DCH

937

QIT Review Letter

06/24

SP

PAMMS

DHS

938

Understanding Medicaid (Spanish)

Gainwell

DCH

939

Understanding Medicaid

Gainwell

DCH

942

IME Verification Form

08/24

PAMMS

DHS

943

Notification of Deduction of Medical Expense

06/24

PAMMS

DHS

944

IME Query Form

06/24

PAMMS

DCH

945

QIT Trustee Guide

06/24

SP

PAMMS

DCH

946

QIT Frequently Asked Questions and Worksheet

06/24

SP

PAMMS

DCH

947

QIT Approved Format Deviation

08/24

PAMMS

DHS

948

QIT Approved Template 1

08/24

PAMMS

DCH

949

QIT Checklist

08/24

PAMMS

DCH

950

Facility Action Request

10/12

PAMMS

DHS

954

OptumRx Prescription Update Template

06/24

PAMMS

DHS

955

Notice of Review of Promissory Note Loan or Property Agreement

06/24

SP

PAMMS

DHS

956

Special Needs Trust Routing Form

08/24

PAMMS

DHS

958

Nursing Facility Information Request

06/24

PAMMS

DHS

960

IME Pricing Document

08/24

PAMMS

DCH

962

Certification of Medicaid Eligibility

07/23

SO

DHS

963

Medicaid Notification Form

01/07

I

SO

DHS

966

Absent Parent Information Form

08/24

SP

PAMMS

DHS

967

Non-Emergency Medical Transportation Information Sheet (NEMT)

08/24

SP

PAMMS

DCH

968

MN PL Budget Sheet

10/12

PAMMS

DHS

969

Living Arrangement Determination - LA/ISM Guide

10/12

PAMMS

DHS

970

VA Communication Form

08/24

SO

DHS

973

Medicaid Review Response Form

12/24

SO

DHS

984

Burial Contract Verification

07/24

PAMMS

DHS

985

Burial Exclusion and Designation

08/24

PAMMS

DHS

986

MAO Cemetery Lot Verification

08/24

PAMMS

DHS

987

Designation of Cemetery Lot

08/24

PAMMS

DHS

988

Notice of Review of Annuity

06/24

SP

PAMMS

DCH

991

MAO Property Search Record

08/24

SO

DHS

995

Pathways Qualifying Activities Report Form

07/23

PAMMS

DHS

996

Pathways Good Cause RM and RA Form

07/23

PAMMS

DHS

998

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

08/24

SP

PAMMS

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

5459

Authorization for Release of Information

07/16

SP

SO

DHS

5460

Notice of Privacy Practices

12/23

SP

PAMMS

DHS

5460

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

Hard Copy Only

DHS

G-845-S

INS SAVE Document Verification

www.uscis.gov

DHS

SS-5

Application for a Social Security Card

www.ssa.gov/forms

Social Security

Foster Care Worker Card

04/04

PAMMS

DHS

GMWD Fact Sheet

09/17

PAMMS

DHS

ICAMA Member Contact List

DHS

ICAMA Non-Member Contact List

DHS

IV-E Budget Sheet

10/12

PAMMS

DHS

(Medicare) Part D Complaint Checklist

PAMMS

CMS

TEFRA/Katie Beckett Cover Letter

05/12

PAMMS

DHS

TEFRA/Katie Beckett Cover Letter (Spanish)

04/05

PAMMS

DHS

TEFRA/Katie Beckett Worksheet

08/11

PAMMS

DHS

Women’s Health Medicaid Physician’s Statement of Treatment

09/23

Gainwell

DHS

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

04/23

Gainwell

DHS

Women’s Health Medicaid Review Form (Obsolete as of 12/2022)

01/14

DHS