Home
About Us
Services
Contact Us
GAPP Forms
GAPP Referral
Discharge/Transfer Notice
Transfer Request
Shared Hours Request
Freedom of Choice
Medical Necessity
Blog
Patient Login
Patient Register
GAPP Medical Necessity Statement
Appendix H / H-1 - Georgia Pediatric Program
Form Type
Skilled Nursing (Appendix H)
Behavioral Health (Appendix H-1)
Member Information
Member Name
*
Date of Birth
*
Weight (lbs)
Medicaid Number
*
DFCS Information
Child is in DFCS Custody
DFCS Worker Name
DFCS Worker Address
Service Hours
Skilled Nursing Hours (weekly)
0-168 hours per week
PSS Hours (weekly)
0-168 hours per week
Additional Information
Receiving Other Services
Family/Paid Caregiver
In School
Has IEP
Personal Nurse at School
School Hours per Day
Rationale if school age not attending
Has Private Insurance
Other GAPP Members in Home
Caregiver Competence Documented
PA Number
Signatures
Caregiver/Legal Guardian Name
Caregiver Signature Date
Agency Representative Name
Agency Signature Date
Attachments
(Optional)
PDF, DOC, DOCX, JPG, PNG - Max 10MB each. You can select multiple files.
Cancel
Submit Statement
