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Fillable DMA 6 form (pdf) - Georgia.gov - georgia

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Type of Program: Nursing Facility GAPP TEFRA/Katie Beckett PEDIATRIC DMA 6(A) PHYSICIAN'S RECOMMENDATION FOR PEDIATRIC CARE Section A ­ Identifying Information 1. Applicant's Name/Address: 2. Medicaid Number: 3. Social Security Number 4. Sex ---------------------------------------DFCS County___ ___ Mailing Address 7. Does guardian think the applicant should be institutionalized? Yes No 5. Primary Care Physician...
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