Appendix F: Forms Table of Contents | Medicaid
Georgia Division of Family and Children Services |
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Policy Title: |
Appendix F TOC: Forms |
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Effective Date: |
June 2025 |
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Chapter: |
Appendix F |
Policy Number: |
Appendix F |
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Previous Policy Number(s): |
MT 73 |
Updated or Reviewed in MT: |
MT 74 |
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 |
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OSAH-1 |
07/23 |
PAMMS |
OSAH |
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6 |
LOC Approval/NH |
Gainwell |
DCH |
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6A |
08/24 |
Gainwell |
DCH |
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59 |
Authorization for NH Facility Reimbursement/Vendor Payment |
Gainwell |
DCH |
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71 |
Medicaid Disability Determination Inquiry (Obsolete as of 09/2013) |
02/11 |
DHS |
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89 |
08/24 |
PAMMS |
DHS |
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94 |
04/24 |
SO |
DHS |
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94A |
05/25 |
SO |
DHS |
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94A Appendix A |
01/24 |
SO |
DHS |
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94A Appendix B |
07/23 |
S0 |
DHS |
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94A Appendix C |
07/23 |
SO |
DHS |
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94A Appendix D |
06/24 |
SO |
DHS |
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106 |
05/25 |
PAMMS |
DHS |
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107 |
06/24 |
PAMMS |
DHS |
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109 |
06/24 |
PAMMS |
DHS |
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118 |
01/22 |
PAMMS |
DHS |
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123 |
Interagency/Interoffice Update and Follow-Up |
Forms OL |
DHS |
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124 |
11/22 |
PAMMS |
DCH |
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125 |
05/23 |
PAMMS |
DCH |
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129 |
06/24 |
PAMMS |
DHS |
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130 |
06/16 |
PAMMS |
DHS |
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136 |
12/24 |
PAMMS |
DHS |
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138 |
Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate with DCSS |
12/24 |
PAMMS |
DHS |
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139 |
12/24 |
PAMMS |
DHS |
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171 |
10/12 |
PAMMS |
DHS |
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172 |
10/12 |
SO |
DHS |
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173 |
06/10 |
PAMMS |
DHS |
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174 |
06/24 |
PAMMS |
DHS |
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184 |
SMEU Data Report |
06/24 |
SO |
DHS |
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185 |
10/12 |
SO |
DHS |
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214 |
08/24 |
SO |
DHS |
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216 |
06/24 |
PAMMS |
DHS |
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217 |
Affidavit to Establish Identity for Medicaid Applicant/Recipients < 16 |
06/24 |
SO |
DHS |
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218 |
06/24 |
PAMMS |
DHS |
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219 |
06/24 |
I |
PAMMS |
DHS |
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223 |
10/12 |
PAMMS |
DHS |
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224 |
10/12 |
PAMMS |
DHS |
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225 |
10/12 |
PAMMS |
DHS |
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226 |
10/12 |
PAMMS |
DHS |
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227 |
Notification of Change in Foster Care or Adoption Assistance |
10/12 |
PAMMS |
DHS |
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238 |
08/11 |
SO |
DHS |
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239M |
04/23 |
PAMMS |
DHS |
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243 |
05/08 |
PAMMS |
DHS |
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245 |
SMEU Request Form |
06/24 |
SO |
DHS |
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252 |
05/25 |
PAMMS |
DHS |
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256 |
Interview Guide for TANF/FS/Medicaid |
SO |
DHS |
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285 |
Third Party Liability |
01/06 |
Gainwell |
DCH |
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297 |
Application for TANF Food Stamps or Medical Assistance. For voter registration information refer to Voter Registration Application Form Information |
10/24 |
SO |
DHS |
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297 |
Application for TANF Food Stamps or Medical Assistance (Arabic Chinese Farsi Hmong Italian Portuguese Russian or Vietnamese) |
Hard Copy Only |
DHS |
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297A |
10/24 |
SO |
DHS |
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297A |
Rights and Responsibilities (Arabic Chinese Farsi Hmong Italian Portuguese Russian or Vietnamese) |
Hard Copy Only |
DHS |
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297M |
Medicaid Addendum to Form 297 (Obsolete as of 12/2021) |
01/14 |
SO |
DHS |
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306 |
08/24 |
PAMMS |
DHS |
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315 |
10/21 |
PAMMS |
DCH |
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326 |
Medically Needy Option Statement |
12/24 |
PAMMS |
DCH |
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327 |
07/22 |
PAMMS |
DCH |
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328 |
06/24 |
PAMMS |
DHS |
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400 |
Medically Needy First Day Liability Authorization for Reimbursement |
05/25 |
Hard Copy Only |
DCH |
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411 |
06/24 |
Screen Print |
DHS |
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412 |
12/24 |
PAMMS |
DHS |
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508 |
Food Stamp TANF Medicaid Renewal Form.For voter registration information refer Voter Registration Application Form Information |
10/24 |
SO |
DHS |
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512 |
06/24 |
PAMMS |
DHS |
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526 |
08/24 |
PAMMS |
DCH |
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700 |
Application for Medicaid & Medicare Savings for Qualified Beneficiaries |
10/22 |
SO |
DHS |
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701 |
08/24 |
SO |
DHS |
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703 |
06/24 |
PAMMS |
DHS |
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704 |
10/04 |
PAMMS |
DCH |
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705 |
05/12 |
PAMMS |
DCH |
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706 |
01/18 |
PAMMS |
DCH |
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713 |
11/10 |
SO |
DHS |
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809 |
12/24 |
SO |
DHS |
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936 |
06/24 |
PAMMS |
DCH |
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937 |
06/24 |
PAMMS |
DHS |
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938 |
Understanding Medicaid (Spanish) |
Gainwell |
DCH |
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939 |
Understanding Medicaid |
Gainwell |
DCH |
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942 |
08/24 |
PAMMS |
DHS |
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943 |
06/24 |
PAMMS |
DHS |
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944 |
06/24 |
PAMMS |
DCH |
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945 |
06/24 |
PAMMS |
DCH |
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946 |
06/24 |
PAMMS |
DCH |
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947 |
08/24 |
PAMMS |
DHS |
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948 |
08/24 |
PAMMS |
DCH |
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949 |
08/24 |
PAMMS |
DCH |
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950 |
10/12 |
PAMMS |
DHS |
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954 |
06/24 |
PAMMS |
DHS |
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955 |
Notice of Review of Promissory Note Loan or Property Agreement |
06/24 |
PAMMS |
DHS |
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956 |
08/24 |
PAMMS |
DHS |
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958 |
06/24 |
PAMMS |
DHS |
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960 |
08/24 |
PAMMS |
DCH |
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962 |
Certification of Medicaid Eligibility |
07/23 |
SO |
DHS |
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963 |
Medicaid Notification Form |
01/07 |
I |
SO |
DHS |
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966 |
08/24 |
PAMMS |
DHS |
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967 |
Non-Emergency Medical Transportation Information Sheet (NEMT) |
08/24 |
PAMMS |
DCH |
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968 |
10/12 |
PAMMS |
DHS |
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969 |
10/12 |
PAMMS |
DHS |
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970 |
08/24 |
SO |
DHS |
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973 |
Medicaid Review Response Form |
12/24 |
SO |
DHS |
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984 |
07/24 |
PAMMS |
DHS |
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985 |
08/24 |
PAMMS |
DHS |
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986 |
08/24 |
PAMMS |
DHS |
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987 |
08/24 |
PAMMS |
DHS |
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988 |
06/24 |
PAMMS |
DCH |
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991 |
08/24 |
SO |
DHS |
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995 |
07/23 |
PAMMS |
DHS |
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996 |
07/23 |
PAMMS |
DHS |
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998 |
Notice of Termination of Medicaid Benefits Due to Contract(s) |
08/24 |
PAMMS |
DHS |
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1610-U2 |
Public Assistance Agency Information |
02/82 |
SSA |
Social Security |
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3327 |
Health Check Brochure |
10/22 |
Gainwell |
DCH |
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3328 |
Health Check Brochure (Spanish) |
Gainwell |
DCH |
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5459 |
07/16 |
SO |
DHS |
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5460 |
12/23 |
PAMMS |
DHS |
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5460 |
Notice of Privacy Practices (Arabic Chinese Farsi Hmong Italian Portuguese Russian Vietnamese) |
Hard Copy Only |
DHS |
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G-845-S |
INS SAVE Document Verification |
DHS |
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SS-5 |
Application for a Social Security Card |
Social Security |
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04/04 |
PAMMS |
DHS |
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09/17 |
PAMMS |
DHS |
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DHS |
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DHS |
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10/12 |
PAMMS |
DHS |
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PAMMS |
CMS |
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05/12 |
PAMMS |
DHS |
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04/05 |
PAMMS |
DHS |
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08/11 |
PAMMS |
DHS |
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09/23 |
Gainwell |
DHS |
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Women’s Health Medicaid Physician’s Statement of Treatment (Spanish) |
04/23 |
Gainwell |
DHS |
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Women’s Health Medicaid Review Form (Obsolete as of 12/2022) |
01/14 |
DHS |