Georgia Pediatric Program (GAPP) Intake Form

Georgia Pediatric Program (GAPP) Intake Form

Please complete this form to start the approval process for no-costin-home nursing and personal care assistance for your child through Medicaid.Atlanta House Healthcare Services will assist you with eligibility,documentation, and securing services as quickly as possible.
Child Information
Child’s Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Does your child have Medicaid?
Medicaid ID Number
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Best Time to Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Quick Eligibility
Is your child medically fragile?
Does your child require nursing care?
Has your child ever received in-home care services before (i.e. nursing care)?
When would you like nursing care and/or personal care assistance to begin?
Medical Profile
Primary Diagnosis
Secondary Diagnoses
Physician Name
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Hospital/Clinic Name
Does your child have seizures?
Medical Conditions (Select all that apply)
Functional Status
Mobility
Communication
Toileting
Daily Care Needs (Select all that apply)
Skilled Care Needs (Select all that apply)
Therapies & School
Is your child enrolled in school?
School Hours
Is there a nurse at school?
Therapies (Select all that apply)
Does your child have an Individualized Education Plan (IEP)?
Additional Health Details
Please list any additional health concerns we need to be aware of
Personal Notes
Anything we should know to provide the best care
Consent
eSignature
Should be Empty:

Georgia Pediatric Program (GAPP) Intake Form

Child Information

Parent/Guardian Information

Quick Eligibility

Medical Profile

Functional Status

Therapies & School

Additional Health Details

Personal Notes

Consent