Get Dch Private Home Care Provider Form

Filling out the Dch Private Home Care Provider Form online can streamline your application process. This guide provides clear, step-by-step instructions to assist you in completing each section accurately.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to download the Dch Private Home Care Provider Form and open it in the editor.
2. In Section A, provide your identification details including the type of application (initial, renewal, change of ownership) and fill in the date of application.
3. In Section B, indicate the type of ownership by circling the appropriate option (proprietary or non-profit) and fill out the name and address details.
4. Section C requires listing the names and addresses of all owners with a minimum of 5% interest. Include the name of the legal governing body.
5. In Section D, list the counties in Georgia where you intend to provide services.
6. Section E focuses on staffing options for your agency. Circle the applicable staffing methods: nursing services, personal care services, or companion/sitter services.
7. In Section F, calculate and enter the full-time equivalent staff, specifying details for registered nurses, licensed practical nurses, personal care assistants, and others.
8. Section G addresses client information; indicate whether you currently have clients, and if not, if you had clients within the last 12 months.
9. In Section H, certify the completion of electronic/live scan fingerprints as required by law, providing the date of completion.
10. Finally, ensure the form is signed and dated by the administrator or an authorized officer, and save the form once completed. You can download, print, or share the finalized form as needed.

Complete your Dch Private Home Care Provider documentation online today!