GA · guidance
Ga. Medicaid Part II Policies & Procedures for Hospice Services, Appendix B
Hospice CAP Rate Data Request Form
Georgia Department of Community Health
Non-Institutional Reimbursement Unit
2 Martin Luther King Jr Dr. SE, East Tower 17th Floor,
Atlanta, GA 30334
HOSPICE FACILITY: FREESTANDING HOSPITAL BASED
Medicaid Provider Name:
Medicaid Provider ID:
Street address:
City: State: Zip Code:
COUNTY:
COST REPORTING FY: FROM: TO:
CAP RATE REPORTING PERIOD: TO:
Enter information from agency’s records for CAP reporting period November through October
CONTINUOUS HOME CARE
(Unduplicated Days, Beneficiaries & Medicaid Payments)
ROUTINE HOME CARE
(Unduplicated Days, Beneficiaries & Medicaid Payments)
INPATIENT RESPITE CARE
(Unduplicated Days, Beneficiaries & Medicaid Payments)
GENERAL INPATIENT CARE
(Unduplicated Days, Beneficiaries & Medicaid Payments)
ENROLLED AIDS PATIENTS
(Unduplicated Days, Beneficiaries & Medicaid Payments)
TOTALS
How many Medicaid members transferred in from another hospice facility?
How many Medicaid members transferred out to another hospice facility?
Medicaid XIX
Beneficiaries
Medicaid XIX
Days
Medicaid XIX
Medicaid Payments
Officer or Administrator of Agency: (Print)
Title:
Signature:
Contact Phone Number:
For assistance, please send an email to DCH_NIR@dch.ga.gov
Information is requested pursuant to Part II Policies and Procedures for Hospice Services Sections 1006 and 1008
Provenance
- Source
- www.mmis.georgia.gov
- Retrieved
- 2026-10-01
- Edition
- pp-hospice-2026-10-01
- Content hash
16b377a5ef8f5c10b59dd6c04226906dea03c8c5f4cbcf3c7902e294eb36a234
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