Georgia Gateway Client Application

  • Georgia Department of Human Services Pre Qualification Questionnaire

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  • Format: (000) 000-0000.
  • Are you applying for the first time, renewal, or to update information?*
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  • What service are you applying for?*
  • Please select what describes your situation (Medicaid eligibility requirements):
  • If applying for MEDICAID/SNAP, PLEASE CHECK EACH BELOW to verify you understand these are the requirements and documentation proof to bring on your appointment:*
  • If applying for CAPS (childcare), PLEASE CHECK EACH BELOW to verify you understand these are the requirements and documentation proof to bring on your appointment:*
  • If you are applying for TANF services, PLEASE CHECK EACH BELOW to verify you understand these are the requirements and documentation proof to bring on your appointment:*

  • By clicking SUBMIT, you confirm and agree to share your information with ICNA Relief case managers. A certified case manager will contact you to schedule an appointment. important Note: All appointments require you to appear in person at our office. By clicking SUBMIT, you also agree to bring all required documents to your scheduled appointment. Failure to bring the necessary documents will result in the cancellation of your appointment, and you will be required to complete this form again.

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