The Georgia Collaborative Aso Request for Conversion Form 2025

1. Click ‘Get Form’ to open the Georgia Collaborative ASO Request for Conversion Form in our editor.
2. Begin by checking the type of change being reported—either Community Living Arrangement (CLA) or Personal Care Home (PCH). Mark your selection clearly.
3. In the 'Current Provider Information' section, enter the agency's business name as it appears on file with DBHDD. This ensures accurate identification.
4. Next, complete the 'Licensed Home Information' section. Fill in the name and address of the CLA or PCH license, along with the telephone number and current Georgia Medicaid Provider Number assigned to this home.
5. Indicate the number of individuals currently receiving DD Residential Waiver Services in your licensed home.
6. Ensure all required signatures are obtained from the Current Provider, Licensed/Host Home Provider, and DBHDD Regional Field Office. Each party must sign and date to attest to the accuracy of the information provided.
7. Finally, return this form along with any necessary attachments via email or mail as specified at the bottom of the form.

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