Medicaid Waiver Application

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 start the waiver application.

About 10–15 minutes
Answer what you know — an estimate is better than a blank.
No commitment
Signing does not commit you to using our services.
Used only for the waiver
Used to apply for the waiver and arrange care — the same purpose the authorization states.

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 relevant medical records.

Who may receive it

I authorize Healthcare Support Home Care, LLC to receive that information, and to disclose it to the support coordination (case management) agency assigned to the application, 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.

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.

I authorize the doctors, hospitals and other providers listed above to release the records described, including the History & Physical, to Healthcare Support Home Care, LLC.*I authorize Healthcare Support Home Care, LLC to share those records with the support coordination (case management) agency assigned to the application and with the state agencies handling the waiver application.*I have read and understood this authorization, including my right to cancel it, and I know I am entitled to a copy.*

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.

I also authorize release of records about HIV/AIDS, mental health or psychiatric treatment, drug or alcohol treatment, and genetic testing.

Signature

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

Fields marked * are required.

Questions, or would you rather do this by phone? Call (404) 375-7808 — we are happy to fill it in with you.