Skip to main content
Georgia Department of Community Health logo Georgia MMIS
  Wednesday, May 25, 2016
Skip to Provider Information Subsystem Menu

  Bookmark star  <- Bookmarkable Link   Bookmark star and question mark Click here for help and information about bookmarks


User Information

Login/Manage Account

PDF Reader Required
NOTE: If you don't have a PDF reader already installed, Adobe Acrobat Reader is required to view these documents. Click here to obtain the latest version of the free Adobe Reader.
File Download Issues
Some users may have difficulty downloading files. Often this is caused by pop-up windows being blocked or by security settings in the browser. Click here for help with download issues.

Forms (85 rows returned) List

Forms (85 rows returned)

 TitleFile TypeCategorySize (KB)Release Date 
Austism Services Attestation FormPDFALL CATEGORIES197.3002/10/2016 
Authorization and Release of InformationPDFALL CATEGORIES207.8008/11/2015 
Catamaran 835 Payment Advice Request FormPDFPHARMACY24.7001/16/2013 
Claim Attachment CoversheetPDFCLAIMS179.9005/27/2015 
Dental Claim FormPDFCLAIMS57.1010/27/2010 
Dialysis DMA 615 ESRD Enrollment Application PDFENROLLMENT466.1006/24/2013 
Disclosure of Ownership Provider OnlyPDFALL CATEGORIES202.7005/13/2015 
DMA 632 632H PE Medicaid Application Page 2PDFALL CATEGORIES93.2007/01/2014 
DMA 632 PE Pregnant Women Medicaid Application PDFALL CATEGORIES116.2007/01/2014 
DMA 632H PE Medicaid Application page 1PDFALL CATEGORIES242.1008/20/2015 
DMA 632W PE ACA Women's Health Medicaid ApplicationPDFALL CATEGORIES64.1007/01/2014 
DMA 632W PE Womens Health Medicaid Application PDFALL CATEGORIES63.8007/01/2014 
DMA 632W PE Womens Health Medicaid Application Page 2PDFALL CATEGORIES148.1007/01/2014 
DMA 634 Approval Notice of ActionPDFALL CATEGORIES75.4007/01/2014 
DMA 634 Denial Form PDFALL CATEGORIES70.9004/01/2014 
DMA 634 Denial Notice of ActionPDFALL CATEGORIES70.9007/01/2014 
DMA 634W Approval Notice of ActionPDFALL CATEGORIES73.6007/01/2014 
DMA 634W Denial Notice of ActionPDFALL CATEGORIES70.3007/01/2014 
DMA-285: Third Party Liability QuestionnairePDFCLAIMS20.7010/27/2010 
DMA-292: Request for Forms or HandbooksPDFALL CATEGORIES223.1003/10/2011 
DMA-312: COB/TPL Accident Information ReportPDFPRIOR AUTHORIZATION220.5009/21/2015 
DMA-322: Exceptional Transport PA RequestPDFPRIOR AUTHORIZATION77.7011/12/2010 
DMA-400: Medically Needy First DayPDFCLAIMS78.6010/27/2010 
DMA-410: COB Notification FormPDFCLAIMS105.3010/27/2010 
DMA-460: Medicare Notification FormPDFCLAIMS97.6010/27/2010 
DMA-501: Claims Adjustment RequestPDFCLAIMS166.6003/28/2016 
DMA-521: Hospice Referral Form for Non-Hospice Related Svcs.PDFPRIOR AUTHORIZATION58.9010/27/2010 
DMA-526: Physician''s Statement for EMAPDFALL CATEGORIES12.9010/20/2010 
DMA-550: Newborn Medicaid CertificationPDFALL CATEGORIES66.4010/20/2010 
DMA-59: Authorization for Nursing Facility Reimbursement FormPDFALL CATEGORIES76.5010/20/2010 
DMA-6PDFALL CATEGORIES114.4001/01/2013 
DMA-610: Prior Authorization RequestPDFPRIOR AUTHORIZATION90.9011/12/2010 
DMA-615: End Stage Renal Disease Enrollment Application PDFPRIOR AUTHORIZATION103.2010/27/2010 
DMA-635: Attestation of PregnancyPDFALL CATEGORIES2110/20/2010 
DMA-69: Informed Consent for Voluntary SterilizationPDFCLAIMS65.8010/27/2010 
DMA-6: Physician''s Recommendation For Nursing Facility CarePDFALL CATEGORIES63.6010/20/2010 
DMA-6A: Physician Recommendation for Pediartic Care PDFALL CATEGORIES93.9012/27/2011 
DMA-6A: Physician Recommendation for Pediartic Care InstructionsPDFALL CATEGORIES170.2003/29/2012 
DMA-710: Credit Balance ReportPDFCLAIMS48.2010/27/2010 
DMA-80: Prior Authorization RequestPDFPRIOR AUTHORIZATION85.2011/12/2010 
DMA-81: Prior Approval for Medical ServicesPDFPRIOR AUTHORIZATION92.3011/12/2010 
DMERC Approval for Immunosuppressive DrugsPDFPHARMACY43.6010/27/2010 
Fax Cover Sheet for Provider Enrollment (Paperless Initiative)PDFALL CATEGORIES178.4005/21/2015 
Form W-9PDFALL CATEGORIES109.6009/25/2013 
Georgia Watch FormPDFPHARMACY40.6001/16/2013 
Georgia Watch Form PDFALL CATEGORIES40.6001/16/2013 
GHP-200: Hospital AdmissionsPDFPRIOR AUTHORIZATION214.2008/03/2011 
Hardship Waiver of Application FeePDFALL CATEGORIES23.9005/12/2014 
Health Check/EPSDT Required Equipment FormPDFALL CATEGORIES60.3010/26/2010 
1 2
English | Espa├▒ol | Accessibility | Privacy | AMA & ADA Copyright Report Fraud
© Copyright 2003-2016 Hewlett Packard Enterprise Development LP