This form is used to update provider information for converting a Personal Care Home or Community Living Arrangement to a Host Home by the Georgia Collaborative ASO.
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How to fill out the GA Collaborative ASO Request For Conversion Form online
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.
- Press the ‘Get Form’ button to access the conversion form and open it in your preferred editor.
- 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).
- 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).
- 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.
- 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.
- 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.
- 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!
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What is the Georgia Dbhdd crisis line?
For access to services and immediate crisis help, call the Georgia Crisis & Access Line (GCAL) at 1-800-715-4225, available 24/7.
What is the mission of Dbhdd?
The mission of DBHDD: Leading an accountable and effective continuum of care to support Georgians with behavioral health challenges, and intellectual and developmental disabilities in a dynamic health care environment.
What is the mission statement of Georgia Regional Hospital?
GRHS Mission: Provide and promote local accessibility and choice of services and programs for individuals, families and communities through partnerships, in order to create a sustainable, self-sufficient and resilient life in the community.
Who regulates mental health facilities in Georgia?
Mental Health (MH) and Substance Use Disorder (SUD): The Georgia Department of Community Health (DCH) oversees the state Medicaid program. The state does not have a relevant section 1115 waiver that affects reimbursement of residential services in Institutions for Mental Diseases (IMDs).
What is the now waiver in Georgia?
The NOW and COMP Waiver Programs provider services and support for people with intellectual or developmental disabilities. The Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) provides day-to-day operations in these programs through six regional field offices.
How many employees does the Georgia Department of Behavioral Health and developmental disabilities have?
Careers at DBHDD Our workforce of 4,600 is distributed within four divisions: Behavioral Health, Developmental Disabilities, Hospital Services, Strategy, Technology, & Performance Management, and a group of enterprise-wide offices.
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