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GAPP Discharge/Transfer Notice
Appendix D - Georgia Pediatric Program
Provider Information
Provider Name
*
Provider Number
*
Provider Address
*
GAPP Member Information
Member Name
*
Medicaid Number
*
Status
Status Type
*
Discharge
Transfer
Effective Date
*
Reason for Discharge/Transfer
Reason Category
*
Select a reason...
Caregiver/Legal Guardian Request
Member no longer has skilled nursing/PSS needs
Member expired
Child is no longer Medicaid eligible
UR staff recommends member removal from program
Member has entered a nursing facility
Agency issues
Illegal activities/bodily harm threats
Fails to adhere to Letter of Understanding
Consistently refused to comply with treatments
Agency unable to provide appropriate staff
Transitioning to another waiver program
Additional Details
(if applicable)
Please specify agency issues
Transitioning to which waiver program?
Select program...
ICWP
CCSP
SOURCE
NOW
Nurse Signature
Nurse Name
*
Date
*
Attachments
(Optional)
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