Healthcare Support Home Care, LLC

Medicaid Waiver Application (EDWP)

If you or your family member has Medicaid but not yet a waiver, this is where the process starts. Tell us about the person who needs care, then sign at the bottom so we can collect their medical history and History & Physical from their own doctors and work the application with Visiting Nurses.

It takes about 10–15 minutes. Answer what you know — an estimate is better than a blank, and we will fill the rest in with you. Nothing here commits you to using our services.

Who the waiver is for
Medicaid and insurance
Who is filling this out
Primary care doctor
Other doctors, hospitals and facilities
Medical history
Help needed day to day

Authorization to obtain and share health information

Please read this before signing. You are agreeing to let your doctors send us records, and to let us pass them to the people who decide the waiver application.

What I am authorizing to be released

I authorize the doctors, hospitals, clinics, pharmacies and other providers named in this form to release my — or my family member's — health information to Healthcare Support Home Care, LLC. This includes the History & Physical (H&P), medical history, progress notes, discharge summaries, diagnoses, medication lists, laboratory and imaging results, functional and cognitive assessments, and any other records needed to establish eligibility for the Elderly & Disabled Waiver Program.

Who may receive it

I authorize Healthcare Support Home Care, LLC to receive that information, and to disclose it to Visiting Nurses for support coordination and case management, and to the Georgia Department of Community Health, the Division of Aging Services, the Area Agency on Aging for my county, and their contractors and agents, to the extent they need it to process the application.

Why

The only purpose of this authorization is to apply for, establish eligibility for, and coordinate services under the Elderly & Disabled Waiver Program (EDWP) — delivered through the Community Care Services Program (CCSP) or SOURCE — and to arrange the in-home care that follows if the application is approved.

How long it lasts

This authorization expires one (1) year from the date I sign it, unless I cancel it sooner.

My right to cancel

I may cancel this authorization at any time by writing to Healthcare Support Home Care, LLC at inquiries@healthcaresupporthc.com or by mail. Cancelling stops any future release of information, but it does not undo anything already shared while the authorization was in effect, and it may end the waiver application.

Things I should know

Healthcare Support Home Care, LLC will not refuse to provide care, and my eligibility for benefits will not change, because I did or did not sign this — except that without it the waiver application cannot go forward. Once information is disclosed to the people named above, it may no longer be protected by federal privacy law and could be re-disclosed by them. I am entitled to a copy of this signed authorization.

Georgia law protects some records more strictly than others. Tick the box below only if you also want records about HIV/AIDS, mental health or psychiatric treatment, drug or alcohol treatment, or genetic testing to be included. Leaving it unticked does not stop the rest of the records from being released.

Signature

Sign with your finger, a stylus, or your mouse. This carries the same weight as signing on paper.

Fields marked * are required.