Get H S & R Report Request Form* - Dch Georgia

This guide provides a comprehensive overview of how to effectively fill out the H S & R REPORT REQUEST FORM - Dch Georgia online. By following the outlined steps, users will navigate the form with clarity and ease.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the H S & R REPORT REQUEST FORM and have it open for editing.
2. In the first section of the form, enter the provider name accurately. Ensure that it reflects the official name registered with Medicaid.
3. Input the 'From Date of Service' (DOS) and 'To Date of Service' (DOS). These dates indicate the range of services provided that you are seeking reports for.
4. Fill in the 'From Date of Payment' (DOP) and 'To Date of Payment' (DOP) to specify the payment period relevant to the services listed.
5. Select the 'Type of Report' you require by checking either 'Summary' or 'Detail,' ensuring you understand the associated costs.
6. Specify how you would like to receive the HS&R report by checking one of the options provided: Medicaid, Peachcare, WEB, or CD.
7. Complete the 'Requested By' section with your name, address, and contact phone number to ensure communication regarding your request.
8. Submit the completed form to Lanika Dancy, including your email address for any follow-up communications. Be sure to note the submission date.
9. Finally, review the form for accuracy, then save any changes, and choose to download, print, or share the completed form as needed.

Begin your request by completing the H S & R REPORT REQUEST FORM online today.