TEST SITE:

DO NOT ENTER REGISTRATIONS HERE

NEW FACILITIES ONLY: Please complete the form below. Once the form is submitted please allow 3-5 business days for a response of approval accompanied by your login credentials.

Warnings:

* Provider Type:
Adult Day Centers Adult Residential Mental Health Applicant Initiated Assisted Living Community/Personal Care Home Caregiver Registry Community Living Arrangement DCH-OIG Contractors High Risk Providers Home and Community Based Services (SFC before) Home Health Agency Hospice Intermediate Care Facility/Intellectually Disabled Long Term Care Hospital Narcotic Treatment Program Nursing Home (NH) Private Home Care Provider Provider HCBS (Prov SFC before) SNF/NF Dual Cert Temporary Staffing Service

* Provider Name:

* Contact First Name:

* Contact Last Name:

* Email:

* Phone:

Physical Address

* Address Line 1:

Address Line 2:

* City:

* State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Puerto Rico Palau Virgin Islands Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon N/A New South Wales Bedfordshire Coahuila Baja California Norte Michoacan Morelos Nayarit Nuevo Leon

* Zip:

Mailing Address

Mailing Address is same as Permanent Address

* Address Line 1:

Address Line 2:

* City:

* State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Puerto Rico Palau Virgin Islands Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon N/A New South Wales Bedfordshire Coahuila Baja California Norte Michoacan Morelos Nayarit Nuevo Leon

* Zip:

Please upload a copy of the contract between the entity registering for GCHEXS access and the DCH licensed facility. “Facility” means: (a) A personal care home required to be licensed pursuant to O.C.G.A. § 31-7-12; (b) An assisted living community required to be licensed pursuant to O.C.G.A. § 31-7-12.2; (c) A private home care provider required to be licensed pursuant to O.C.G.A. § 31-7-301; (d) A home health agency required to be licensed pursuant to O.C.G.A. § 31-7-151; (e) A hospice required to be licensed pursuant to O.C.G.A. § 31-7-173; (f) A nursing home, skilled nursing facility, or intermediate care home required to be licensed pursuant to O.C.G.A. § 31-7-1

* File Name:

* Description:

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