Get Ga Collaborative Aso Request For Conversion Form 2023-2026

This guide provides a step-by-step approach to completing the GA Collaborative ASO Request For Conversion Form online. Whether you are familiar with similar documents or a first-time user, this guide aims to simplify the process.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the conversion form and open it in your preferred editor.
2. Begin by selecting the type of change you are reporting, indicating whether it is a Community Living Arrangement (CLA) or a Personal Care Home (PCH).
3. In the current provider identification section, fill in the agency's business name exactly as it appears on file with the Department of Behavioral Health and Developmental Disabilities (DBHDD).
4. Complete the licensed home information by including the name and address found on the CLA or PCH license. Additionally, provide the contact number for the licensed home and the current Georgia Medicaid Provider Number assigned to this location. Don't forget to mention the number of individuals currently receiving DD Residential Waiver Services in this home.
5. In the signatures section, ensure that the current provider, the licensed/host home provider, and a representative from the DBHDD Regional Field Office sign and date the form. All parties must agree to the attestation for the change to be approved.
6. Once the form has been completed and signed, return it along with any required attachments. You may submit the form via email to GAEnrollment@Carelon.com or mail it to the Georgia Collaborative Enrollment at 740 West Peachtree St NW, Atlanta, GA 30308.
7. Finally, ensure that you save your changes to the form. You may also choose to download, print, or share the document as needed.

Complete the GA Collaborative ASO Request For Conversion Form online today!