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Appendix R - Georgia Pediatric Program
Request Information
Transfer Request Date
*
GAPP Member Information
Member Name
*
Date of Birth
*
Medicaid Number
*
Current Agency Information
Current Agency Name
*
Contact Person
Phone
Current Hours Approved
Weekly hours (0-168)
Current PA Expiration Date
Appendix Submission Date
Reason for Transfer
Please explain the reason for this transfer request
*
Receiving Agency Information
Receiving Agency Name
*
DMA-80 Submission Date
Caregiver/Legal Guardian Signature
Caregiver Name
*
Signature Date
*
Phone
Attachments
(Optional)
Upload supporting documents
PDF, DOC, DOCX, JPG, PNG - Max 10MB each. You can select multiple files.
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