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  Friday, December 4, 2020
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(click to hide) Alert Message posted 3/27/2020
Alert:
In response to the Centers for Medicare & Medicaid Services (CMS) approval of Medicaid Section 1135 Waivers for COVID-19, the State of Georgia Department of Community Health will expedite new enrollment applications until further notice.
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Forms (29 rows returned) List
 
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Forms (29 rows returned)

 
 TitleFile TypeSize (KB)Release Date 
Access to Initial Application LettersPDF298.501/15/2020 
Appendix FF - Notice of Intent to Become a CCSP Service ProviderPDF315.102/16/2018 
Appendix HH - CCSP Application ChecklistPDF250.902/16/2018 
Attestation Form for Specialty Provider for Autism ServicesPDF252.403/22/2018 
Authorization and Release of Information FormPDF156.609/03/2019 
CCSP & Source Standard Assurances FormPDF62.802/03/2020 
CVO Required Documents ChecklistPDF75.905/31/2017 
Delegated Credentialing Entity Attestation FormPDF91.803/22/2018 
Disclosure of Ownership and Control Interest Statement - Contractors OnlyPDF648.904/09/2019 
Disclosure of Ownership and Control Interest Statement - Contractors Only-NEMTPDF635.704/09/2019 
Disclosure of Ownership and Control Interest Statement - Providers OnlyPDF611.604/09/2019 
Disclosure of Ownership and Control Interest Statement - Trading Partners OnlyPDF630.804/09/2019 
Durable Medical Equipment (DME) Licensure Exemption Attestation FormPDF155.205/17/2018 
Electronic Funds Transfer Agreement (EFT) Web Portal InstructionsPDF64.605/31/2017 
Hardship Waiver of Application FeePDF23.905/12/2014 
LEA Attestation FormPDF246.503/18/2016 
Power of Attorney for Payee (POA)PDF12.509/25/2013 
Power of Attorney Instructions (Individual Practitioner)PDF2612.105/31/2017 
Pregnancy Related Services QuestionnairePDF493.805/31/2017 
Professional Liability Claims Information FormPDF41.105/31/2017 
Provider Enrollment CoversheetsPDF1505.703/05/2018 
Required Documentation to enroll with Georgia MedicaidPDF468.306/20/2019 
Step By Step Instructions on How to Complete the Power of Attorney Form (Facility)PDF2101.905/31/2017 
Step By Step Instructions on How to Complete the Power of Attorney Form (Individual Practitioner)PDF2892.305/31/2017 
Step By Step Instructions on How to Complete the W9 Form (Facility)PDF1746.805/31/2017 
Step By Step Instructions on How to Complete the W9 Form (Individual Practitioner Paying the Social Security Number)PDF1431.305/31/2017 
Step By Step Instructions on How to Complete the W9 Form (Individual Practitioner)PDF1697.505/31/2017 
W-9 InstructionsPDF42.505/31/2017 
W9 FormPDF84.405/31/2017 
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