After embracing a huge learning curve on the basics of Katie Beckett in Georgia, you are fast becoming a pro as you're moving through your application. You've set up your organizational system (Step 1), booked needed appointments (Step 2), requested follow-up reports and notes, and are working on getting your Physician Forms completed with your child's provider(s) (Step 3). While you are waiting for all of those things to come to full fruition, this is a great time to fill out your Personal Forms (Step 4). This process will be MUCH easier than the Physician Forms; it's just you, your computer, and a small bit of assistance from your employer.

These are the items you'll be completing for the Personal Forms portion of your Katie Beckett Medicaid Application in Georgia. Click on the links to scroll directly to each section, where you'll find step-by-step instructions, a link to download each blank form, and an example filled out for your reference.

Blank Forms from GA Medicaid Site

Click through to download your blank starting forms from the GA TEFRA Katie Beckett Medicaid website.

Medicaid Application Form

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Voter Registration Declaration

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Supplemental Documents

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Medicaid Application (Form 94)

This will be the first form in your application package. It's pretty straightforward, but has a couple of quirky aspects, so here is a step-by-step on how to fill it out.

Page 1 instructions:

  1. At the very top, it says 'Check block(s) that apply to you:' - the problem is that there is not a box that applies to you. So, what you'll want to do is type 'Katie Beckett' in the empty space next to 'Check block(s) that apply to you:'. Just to the right, check whether or not the child was in foster care on their 18th birthday. Since the Katie Beckett waiver application is for children, this should be 'No.'
  2. For this application, your child is the applicant, so you'll list the child's information in the top box: name, mailing address, city, state, & zip code. If your residence address is different from your mailing address, add that under 'Residence Address.' Put a parent's email address in the 'Email Address' field. LEAVE THE DATE BLANK. All dates must match across your forms, so the dates will be completed in a later step.
  1. In the second box area, you'll list all persons that you want to apply for Medicaid. For Katie Beckett, you'll only list the child or children in your household who would potentially qualify under a high level of care need. Enter the child's name, race, sex, date of birth, relationship to you ('Self' since the child is the applicant), and Social Security number. Indicate with Y for yes or N for no the answers to the questions in the last three columns.
  2. In the third box area, you'll list all of those living in the household who are NOT applying for Medicaid. For Katie Beckett, this would be all adults and any children you are NOT applying for Medicaid. List each person's name, race, sex, date of birth, relation to the child you're applying for (i.e. parent/sibilng), Social Security number, and indicate with Y or N in the three questions to the right. If there are more folks in the house than will fit on these lines, you can make a note to see 1 or 2 additional folks listed in the space at the bottom of the page, or create an attachment page listing the same information for all other members of the household.
  3. Under this third box area, there are a few questions to answer. Check if anyone is pregnant, and if so, who and what the due date is. MOST IMPORTANTLY, answer the question if you have any unpaid medical bills from the past three months. Medicaid can back date your approval up to three months, allowing your providers to submit previous bills to be paid by Medicaid. So if you have bills you'd like to have potentially covered by Medicaid in the past three months, check 'Yes' and then indicate which months you have medical bills you'd like to be considered.
  4. Also under this third box area, answer if anyone in your household has health insurance - this is if you have a primary insurance through an employer, as an example. If you have any existing health insurance coverage, check 'Yes' and list the Insurance company name and policy number our to the right.
  5. At the very bottom, check if someone has been diagnosed with breast or cervical cancer and the question that follows if so.

Page 2 Instructions:

  1. For the top section, you don't have to complete the entire section because you aren't applying for Medicaid based on your income or assets. If you were able to qualify based on being underneath the cutoff for Medicaid based on income, your application is a MUCH simpler process. If you are applying for Medicaid based on a level of care need for your child, the only portion of this top financial box that you need to fill in is your basic income information to show that you do NOT qualify for Medicaid based on income. List your Gross amount per paycheck (NOT final take-home pay), how often that paycheck comes to you, and the name of the person making that wage. Also list your current employer underneath.
  2. Just under the financial box, there is an area to indicate if you pay for day care for your child so that someone can work. You may qualify for Medicaid assistance with these funds if you fill in this box, so definitely complete that section if that applies to you.
  3. If the next box applies to you and a parent does not live in the home with the child, make sure you complete that section as well.
  4. Leave the signature and date areas at the bottom BLANK until a later step.

Page 3 instructions:

  1. This one should be simple! List the child's name that you are applying for Medicaid in the top box. List their place of birth and check their citizenship status to the right.
  2. Fill in your name in the 'print name' blank in the middle of the page. Leave the signature and date spots BLANK until a later step.
  3. Since you are applying under the Katie Beckett waiver, which only applies to children, you should be leaving the bottom area box blank.

Third Party Liability Questionnaire

Unfortunately, this form is not included on the Katie Beckett website, even though it is required as part of your application. It's also a bit hard to find online. To download a blank form, click here. To view a filled-in example for your reference, click here.

  1. Where it says 'Case Name,' this will be your child's name that you are applying for Medicaid benefits. List your address, phone number, and the child's Social Security number. Leave 'Case No.' blank since this is your initial application.
  2. For 'Type of Case,' check 'Initial Application.'
  3. 'Do you have a private, group or government health insturance that pays the cost of your medical care?' This question definitely threw me for a loop at first. For this question, it is asking if you have any other entity you've already been approved for that pays the entirety of the cost of the medical care for your child you are applying for Medicaid benefits. This could be a government entity if you are already on another plan (PeachCare at 100% coverage, military health care coverage, etc.), or a private health insurance coverage IF it covers all expenses at 100% (which is rare, but does exist). For most of the average population, this would be checked 'No.'

Third Party Liability Form

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  1. 'Does your spouse, parent, or stepparent have any private, group, or government health insurance that pays any of the cost of your medical care?' This question is asking if the child (in this case) applying for Medicaid benefits has existing coverage through a parental figure that covers some portion of the medical care. If you have any existing health insurance coverage, your answer would be 'Yes.' If you have zero health insurance of any kind, your answer would be 'No.'
  2. 'Is the policyholder an Absent Parent?' - check the applicable answer. If the person whose policy provides some/total coverage is absent, you would check 'Yes.'
  3. 'Names of Covered Individuals in Household' - since this is your initial application, enter 'None currently covered by Medicaid' and leave this box blank.
  4. 'Do any of the persons listed above have a chronic medical condition?' - check YES and list your child's name and their primary / dominant condition/diagnosis.
  5. In the section at the bottom, enter the information for any existing health insurance coverage. Policy effective date would be the last 'renewal' date of the policy (January 1 for most folks), and the policy termination date would be the date the current policy would 'expire' (December 31 for most folks).
  6. List the Employer's information that provides this existing health insurance coverage - their name, address, and telephone number.
  7. For 'Types of Coverage', this one can be confusing. You'll circle which types of coverage you have on your existing health insurance policy. You may need to call your health insurance provider to ask them about coverage for each of these.
    • 01 - HOSPITAL INPT. stands for 'Hospital Inpatient.'
    • 07 - DRUG/STND is standard prescription drug coverage.
    • 08 - MAJOR MED. is coverage for major/main medical needs.
    • 09 - DENTAL is dental coverage under your health insurance plan.
    • 10 - VISION would be vision coverage under your health insurance plan.
    • 15 - LTC/NH is coverage for long-term care or nursing home care.
    • 16 - HMO/DRUG is coverage for drugs under an HMO plan.
    • 17 - MED. SUPP A would be a Medicare Supplement A plan.
    • 18 - MED. SUPP B would be a Medicare Supplement B plan.
    • 22 - HMO / STND would be a standard HMO plan.
  8. Leave both signature and date areas at the bottom blank until a later step.

Voter Registration Declaration

This one is pretty straightforward. The only hiccup is that it's hard to find a blank version of the form to fill out. To download a blank version, click here. To view a completed example, click here.

The purpose of this form is for the government to make sure they have provided every opportunity for voters to register in the process of anything you apply for with them. You'll need a form for each member in your household who is of voting age. Fill in their name at the top. Leave the date blank until a later step. Check 'Yes' or 'No' as applicable in the middle section.

That one was easy!

GA Voter Registration Form

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HIPPAA Privacy Policy Notices

This one is also pretty simple. Similar to Voter Registration forms, it's hard to find a blank version of this one to fill out. To download a blank version, click here. This one is so easy, we don't even need a completed example. 🙂

This form is required for anything you apply for through the GA Department of Health. You'll need one of these for each adult in your household. You can fill in your name on the last page, but leave the date and signature blank until a later step.

We're killin' it with this section! Almost done!

HIPPAA Privacy Policy Notice

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Supplemental Documentation

For this part, we'll gather a few scans/copies of things you'll need to include in your final application packet.

  1. Your child's birth certificate - Make a copy or scan of your child's birth certificate. You do NOT need to send in the original (please don't!).
  2. Make a copy or scan of the front and back of your primary insurance card.
  3. Paystubs for two most recent pay cycles - make copies or scans of your two most recent paystubs. You may need to update this closer to the time of sending in your application.
  4. Articles or letters from specialists if your child has a rare/unknown condition - In our case, our daughter's condition was super rare and something the average person reviewing our application would know nothing about. We chose to include three medical journal articles about her condition at the end of our application package so that they could learn more about it if they wanted to. We also included a personal letter from the primary doctor in the world on this disorder, which supported our approach to increasing her frequency of therapies as the main approach to treatment.
  5. You will include the past 12 months of your child's medical record which you requested in Step 2. If there are signifiant diagnostic reports from before the prior 12 months (i.e. genetic testing results, blood test results, etc.), those will need to be included as well.
  6. Parent Introduction and Summary - This is optional, but consider writing a brief (less than one page) summary of your child's history, diagnosis, and prognosis. As cold as it may sound, the Katie Beckett review team is looking to use their program for children who will benefit long-term from the investment of medical care. So in your summary, be honest about their challenges while also expressing how much potential they have in the future with the medical support you're requesting. To view an example, click here.

Parent Summary

View an Example

Ready to move on to the next step?

Congratulations, you completed another step! Once you have your personal forms all ready to go, it's time to move on to Step 5 - submitting your final package.