Appendix F Forms Overview

Georgia State Seal

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Forms Overview

Effective Date:

N/A

Chapter:

Appendix F

Policy Number:

Appendix F

Previous Policy Number(s):

Updated or Reviewed in MT:

MT-41

Policy Statement

Only State Office approved forms may be used.

Basic Considerations

Medicaid Eligibility Specialists must not require more of applicant/recipients than placed by federal and state regulations and policies.

System generated notices and forms issued by the State Medicaid Unit and other State agencies are listed in Appendix F.

Use of State Office approved forms safeguards the following:

  • Accessibility of the Medicaid Program

  • Minimization of barriers to applying for benefits

  • Simplification of the renewal process

  • Compliance with the Office of Civil Rights

  • Timely and Adequate notice of eligibility decisions

Forms Issued by Other Policy Units

Information obtained via forms issued by other policy units may be used in making Medicaid eligibility decisions, but should not be routinely used by MES'.

Forms issued by other policy units that will be used by MES' on a regular basis include the following:

  • Form 138, Notice of Requirement to Cooperate with CSS

  • Form 256, Interview Guide for TANF/FS/MAO

  • Form 713, Interagency/Interoffice Referral and Follow-Up

  • Form 809, Verification of Earned Income and Deductions

  • Form 990, Verification of Unearned Income

Administrative Review Forms

Administrative Review Forms are located in Appendix H, Administrative Reviews. These forms may be obtained by screen print or by ordering through the State Office. See instructions later in this section.

Administrative Review Forms include the following:

  • Family Medicaid CAR Selection Guide

  • Family Medicaid Reading Guide

  • Form 965, ABD Medicaid Supervisory Review

  • Form 974, ABD Medicaid Monthly Supervisory Review Summary Sheet

  • Foster Care Supervisory Review Form

  • IV-E Supervisory Review Summary

  • Non-IV-E Supervisory Review Summary

Ordering Forms

Most Medicaid forms are available in MS Word format in Appendix F of the Medicaid Manual found in the Department of Human Services' On-Line Directives Information System (ODIS) www.odis.dhr.state.ga.us.

The Appendix F Table of Contents indicates how to obtain forms.

Screen Print Forms

Screen Print: The form must be printed when accessing ODIS. There is no central printing or storage of this form

DCH Forms

DCH forms should be ordered through the GAMMIS web portal following these procedures:

  1. Go to www.mmis.georgia.gov

  2. Click the “contact us” tab in the upper-right hand corner of the page.

  3. Complete the information in the fields and click “submit”.

The e-mail must include the name and phone number of person ordering the form, the form number and quantity of forms requested, specifying English, Spanish or Braille and the shipping address.

Department of Homeland Security (DHS Forms)

DHS: This form must be printed from the following Department of Homeland Security web site: uscis.gov/graphics/formsfee/forms/files/g-845s.pdf

The instructions for use of the form are at the bottom of page two of the form. Once the form is completed and documentation attached, the form should be mailed to:

U.S. Citizenship and Immigration Services Atlanta District
Martin Luther King, Jr.
Federal Building 77 Forsyth Street, SW
Atlanta, GA 30303

Forms OL

Forms OL: These forms must be printed when accessing DFCS Forms On-Line www.dfcs.dhr.georgia.gov/. From the DFCS home page, click on “About Us”. Then click on “Publications”. Then click on “DFCS Forms On-line”.

SSA Forms

SSA: Social Security Administration (SSA) forms must be printed from the following website:

EXCEPTIONS:

  • Form SS-5 and instructions may be printed from the SSA website. The SS-5 is then submitted to the local SSA office either by mail or in person. The A/R must complete the form.

English version:
www.socialsecurity.gov/online/ss-5.pdf

Spanish version:
www.socialsecurity.gov/online/ss-5sp.pdf

  • Form SS-1610-U2 must be ordered from the local SSA office.

N/A Forms

N/A: These forms are either generated by another agency or are reference only. Screen print is acceptable if available on ODIS.

Secretary of State Forms

Sec State: These forms must be ordered from the Secretary of State’s office at cfuller@sos.state.ga.us. The request should be to the attention of Carol Fuller. Fax requests must be made to 404-657-5367. The UPS shipping address and telephone contact number are required.

State Office Forms

SO: These forms must be ordered through the DFCS State Office.

PeachCare for KidsTM Forms

PeachCare for KidsTM applications and brochures can be ordered by using the PCK Special Request form located in Appendix F. This form can be emailed to sgreen@dch.ga.gov, or faxed to (770)344-3793.