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 Policy Number(s):

MT 73

Updated or Reviewed in MT:

MT 74

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

LOC Approval/NH

Gainwell

DCH

6A

Physician’s Recommendation for Pediatric Care

08/24

Gainwell

DCH

59

Authorization for NH Facility Reimbursement/Vendor Payment

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

05/12

PAMMS

DCH

706

TEFRA/Katie Beckett Medical Necessity LOC Statement

01/18

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