“**Keep in mind that you do not need to mail this printout to your local agency.

**”

“Thank you for using Gateway to apply for benefits!”

SALOME SHEBA your application has been submitted to Online Services on March 20, 2021 at 12:10
AM.
If you submit your application after regular business hours or on a weekend or holiday, your filing date is the
next business day March 22, 2021.
We will review your application and contact you if we need additional information.
If you need to make changes to your TANF, Food Stamps, or Medical Assistance application, please contact
on-line services at 1-877-423-4746.
In your application, you have asked for these benefits:
• Food Stamps (SNAP) – T24532302
Be sure to write the number(s) down or print this page for your records.

As a next step, your worker may ask for proof of some of the things you told us in your application. This checklist
will help you gather these items. If you can not find something, your worker may be able to help you get the proof
you need.

Keep in mind that this list is based only on what you told us today. There may be other items that your worker will
ask you to provide.

Proof of Identity
Proof of who you are, like a driver’s license, ID card.

Proof of Residence
Current Georgia issued Driver License/ID Card, current lease, current mortgage statement, statement from landlord
or person with whom you reside, utility bill (gas, electric, telephone)

Social Security Number

Social Security Numbers for everyone you want to receive benefits. Immigrants may potentially be eligible for
benefits without a social security number. Social Security Number is not required for WIC.

Proof of Citizenship or Immigration Status (Only for those seeking benefits)

Proof of citizenship such as a birth certificate, U.S. passport, hospital record. Proof of immigration status such as
resident immigration card, passport, visa, 1-94, I-181, or other Department of Homeland Security (DHS)
documentation. Additional examples of Proof of Citizenship for Medical applicants can be found in Form 218. Proof
of Citizenship/Immigration Status is not required for WIC.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Application Summary
Here is a summary of what you told us as well as important information about your rights and responsibilities.

Relationship to Applying for

First Name Middle Initial Last Name
Applicant Benefits
Food Stamps
Person1 SALOME SHEBA Self
(SNAP)
Food Stamps
Person2 SHUKURU KAHINDO is the spouse of
(SNAP)
Food Stamps
Person3 EMMANUELLA GRABRIELLA is the daughter of
(SNAP)
is related in Food Stamps
Person4 ESTA NEEMA
another way to (SNAP)

Social Security US Citizenship Pregnant

Date of Birth Gender
Number (Y/N) (Y/N)
Person1 11/06/1990 890-77-8982 Female N N

Person2 01/01/1991 756-35-4981 Male N N

Person3 07/04/2020 126-29-0677 Female Y N

Person4 01/01/2004 875-30-4825 Female N N

Lives in the
Income Tax Dependent Disabled/Blind Expenses
Home
(Y/N) (Y/N) (Y/N) (Y/N)
(Y/N)

Person1 Y N N N Y

Person2 Y Y N N N

Person3 Y N N N N

Person4 Y N N N N

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Application Information- T24532302
Submission Date and Time 2021-03-20 00:10:21.415

Program Information
Programs Food Stamps (SNAP)

Basic Information
Applicant Details
First Name SALOME
Middle Initial
Last Name SHEBA
Suffix --
Gender Female
Date of Birth 11/06/1990
Primary Language
Do you live in Georgia?
County Dekalb
Marital Status
Driver's License/State ID Number 061539019
Issuing State
Expiration Date 07/03/2024
Physical Address
Street Number and Name, P.O. Box Number 869 Arbor Hill Dr
Apartment, Suite, Unit, Building, Floor, etc.
City Stone Mountain
State Georgia
Zip Code 30088-2367
Homeless No
What is your living arrangement? In This Home
If not living at home, what date did
current living arrangement start?
State lived in before moving in to
current living arrangement
Mailing Address
Street Number and Name, P.O. Box Number
Apartment, Suite, Unit, Building, Floor, etc.
City
State
Zip Code
Previous Address
Has the household lived at any other
address in the past year?
Contact Information
Primary Phone (404) 917-5330
Work Phone (404) 917-5330
Extension

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Alternative Phone (404) 857-5964
Email Address [email protected]
What is the best way of getting in touch with you during
Primary Phone
the weekday?
What is the best time to call you during the weekday? Early Morning (8AM-10AM)
When did this information change?

People In Your Home- SALOME SHEBA

Personal Information
First Name SALOME
Middle Initial
Last Name SHEBA
Suffix --
Gender Female
Date of Birth 11/06/1990
What is the primary language of household?
Other Language
If an interview is needed do you need an interpreter? No
What is this person’s Marital Status?
What is this person’s Living Arrangement? In This Home
If person is living out of home, what is the reason?
Program Selection
Programs Food Stamps (SNAP)
Alternative Name Information
Is this person known by any other name? No
First Name
Middle Initial
Last Name RUSIMUKA
Suffix
Social Security Number (SSN) Information
Social Security Number 890-77-8982
If this person doesn't have a Social
Security number (SSN), but has applied for
one, when did he or she apply?
Ethnicity
Ethnicity Other
Race
Race Black / African American
If this person is American
Indian/Alaskan Native, are they a member of
Federally recognized tribe
If yes, tribe name
Personal Information Continued
Does this person live in Georgia?
Is this person Blind or disabled? No
Is this person United States Citizen? No
Immigration Information
What is person’s Immigration status? Refugee

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

When did this person come to US to live? 09/18/2018
What is this person’s Immigration document type? I 551 Permanent Resident Card
What is this person’s Alien registration number? 217060487
Military Information
Are you a veteran or active duty member? No
Is your spouse a veteran or active duty member?
If you are applying on behalf of a child,
is the parent of the child in the home a veteran
or an active duty member?
When did this information change?

People In Your Home- SHUKURU KAHINDO

Personal Information
First Name SHUKURU
Middle Initial
Last Name KAHINDO
Suffix --
Gender Male
Date of Birth 01/01/1991
What is the primary language of household?
Other Language
If an interview is needed do you need an interpreter?
What is this person’s Marital Status?
What is this person’s Living Arrangement? In This Home
If person is living out of home, what is the reason?
Program Selection
Programs Food Stamps (SNAP)
Alternative Name Information
Is this person known by any other name?
First Name
Middle Initial
Last Name
Suffix
Social Security Number (SSN) Information
Social Security Number 756-35-4981
If this person doesn't have a Social
Security number (SSN), but has applied for
one, when did he or she apply?
Ethnicity
Ethnicity Other
Race
Race Black / African American
If this person is American
Indian/Alaskan Native, are they a member of
Federally recognized tribe
If yes, tribe name
Personal Information Continued

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Does this person live in Georgia?
Is this person Blind or disabled? No
Is this person United States Citizen? No
Immigration Information
What is person’s Immigration status? Refugee
When did this person come to US to live? 11/28/2016
What is this person’s Immigration document type? I 551 Permanent Resident Card
What is this person’s Alien registration number? 212834585
Military Information
Are you a veteran or active duty member? No
Is your spouse a veteran or active duty member?
If you are applying on behalf of a child,
is the parent of the child in the home a veteran
or an active duty member?
When did this information change?

People In Your Home- EMMANUELLA GRABRIELLA

Personal Information
First Name EMMANUELLA
Middle Initial
Last Name GRABRIELLA
Suffix --
Gender Female
Date of Birth 07/04/2020
What is the primary language of household?
Other Language
If an interview is needed do you need an interpreter?
What is this person’s Marital Status?
What is this person’s Living Arrangement? In This Home
If person is living out of home, what is the reason?
Program Selection
Programs Food Stamps (SNAP)
Alternative Name Information
Is this person known by any other name?
First Name
Middle Initial
Last Name MARIAMU
Suffix
Social Security Number (SSN) Information
Social Security Number 126-29-0677
If this person doesn't have a Social
Security number (SSN), but has applied for
one, when did he or she apply?
Ethnicity
Ethnicity Other
Race
Race Black / African American

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

If this person is American
Indian/Alaskan Native, are they a member of
Federally recognized tribe
If yes, tribe name
Personal Information Continued
Does this person live in Georgia?
Is this person Blind or disabled? No
Is this person United States Citizen? Yes
Military Information
Are you a veteran or active duty member? No
Is your spouse a veteran or active duty member?
If you are applying on behalf of a child,
is the parent of the child in the home a veteran
or an active duty member?
When did this information change?

People In Your Home- ESTA NEEMA

Personal Information
First Name ESTA
Middle Initial
Last Name NEEMA
Suffix --
Gender Female
Date of Birth 01/01/2004
What is the primary language of household?
Other Language
If an interview is needed do you need an interpreter?
What is this person’s Marital Status?
What is this person’s Living Arrangement? In This Home
If person is living out of home, what is the reason?
Program Selection
Programs Food Stamps (SNAP)
Alternative Name Information
Is this person known by any other name?
First Name
Middle Initial
Last Name
Suffix
Social Security Number (SSN) Information
Social Security Number 875-30-4825
If this person doesn't have a Social
Security number (SSN), but has applied for
one, when did he or she apply?
Ethnicity
Ethnicity Other
Race
Race Black / African American

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

If this person is American
Indian/Alaskan Native, are they a member of
Federally recognized tribe
If yes, tribe name
Personal Information Continued
Does this person live in Georgia?
Is this person Blind or disabled? No
Is this person United States Citizen? No
Immigration Information
What is person’s Immigration status? Refugee
When did this person come to US to live? 04/26/2018
What is this person’s Immigration document type? I 551 Permanent Resident Card
What is this person’s Alien registration number? 212834543
Military Information
Are you a veteran or active duty member? No
Is your spouse a veteran or active duty member?
If you are applying on behalf of a child,
is the parent of the child in the home a veteran
or an active duty member?
When did this information change?

Relationship Information - SALOME SHEBA

Relationships SALOME is the spouse of SHUKURU
SALOME is the mother of EMMANUELLA
SALOME is related in another way to ESTA
Who does this person buy food or eat meals with? SHUKURU, EMMANUELLA, ESTA
When did this information change?

Relationship Information - SHUKURU KAHINDO

Relationships SHUKURU is the father of EMMANUELLA
SHUKURU is the brother of ESTA
Who does this person buy food or eat meals with? EMMANUELLA, ESTA
When did this information change?

Relationship Information - EMMANUELLA GRABRIELLA

Relationships EMMANUELLA is the niece of ESTA
Who does this person buy food or eat meals with? ESTA
When did this information change?

Out of State Benefit Details - SALOME SHEBA

Out of State Food Stamps (SNAP) Benefits
State Georgia
Is this person still receiving Food Stamp (SNAP)
No
Benefits in this state?
What was the last date Food Stamp (SNAP) Benefits
08/31/2020
were received from this state?

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Out of State Medical Assistance Benefits
State Georgia
Is this person still receiving Medical Assistance Benefits
Yes
in this state?
What was the last date Medical Assistance Benefits
were received from this state?
Out of State TANF Benefits
State Georgia
Is this person still receiving TANF Benefits in this state? Yes
What was the last date TANF Benefits were received
from this state?
When did this information change?

Out of State Benefit Details - SHUKURU KAHINDO

Out of State Food Stamps (SNAP) Benefits
State Georgia
Is this person still receiving Food Stamp (SNAP)
No
Benefits in this state?
What was the last date Food Stamp (SNAP) Benefits
08/31/2020
were received from this state?
Out of State Medical Assistance Benefits
State Georgia
Is this person still receiving Medical Assistance Benefits
No
in this state?
What was the last date Medical Assistance Benefits
07/31/2017
were received from this state?
Out of State TANF Benefits
State Georgia
Is this person still receiving TANF Benefits in this state? No
What was the last date TANF Benefits were received
07/31/2017
from this state?
When did this information change?

Out of State Benefit Details - EMMANUELLA GRABRIELLA

Out of State Food Stamps (SNAP) Benefits
State Georgia
Is this person still receiving Food Stamp (SNAP)
No
Benefits in this state?
What was the last date Food Stamp (SNAP) Benefits
08/31/2020
were received from this state?
Out of State Medical Assistance Benefits
State Georgia
Is this person still receiving Medical Assistance Benefits
Yes
in this state?
What was the last date Medical Assistance Benefits
were received from this state?
Out of State TANF Benefits

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

State Georgia
Is this person still receiving TANF Benefits in this state? Yes
What was the last date TANF Benefits were received
from this state?
When did this information change?

Out of State Benefit Details - ESTA NEEMA

Out of State Food Stamps (SNAP) Benefits
State Georgia
Is this person still receiving Food Stamp (SNAP)
No
Benefits in this state?
What was the last date Food Stamp (SNAP) Benefits
08/31/2020
were received from this state?
Out of State Medical Assistance Benefits
State Georgia
Is this person still receiving Medical Assistance Benefits
Yes
in this state?
What was the last date Medical Assistance Benefits
were received from this state?
Out of State TANF Benefits
State Georgia
Is this person still receiving TANF Benefits in this state? No
What was the last date TANF Benefits were received
from this state?
When did this information change?

Current Job Details - SHUKURU KAHINDO

Employer Details
Employer Name Homegoods
Employer Identification Number (EIN)
Address Line1
Address Line2
City
State
Zip Code
Employer's Phone Number
Currently on strike
Has job ended No
When did this job start
Date of First Pay 03/10/2017
End of Job Details
When did this job end
Date of final paycheck
Gross amount of final paycheck
Payment Information
How often does this person get paid? Weekly
Gross amount paid each pay period $545.68
Application T24532302 Rev(11/20) https://gateway.ga.gov/access/
Hours worked each pay period
Hourly pay rate
Additional Information
Additional comments about your job
When did this information change?

Housing Bills Details - SALOME SHEBA

Housing Bill Type Rent
How often does this person pay for this housing?
How much is the total housing bill $1,200.00
How much does this person pay for the housing bill? $1,200.00
Landlord/Property Information
Landlord/Property Name
Address Line1
Address Line2
City
State
Zip Code
When did this information change?

Utility Bill Details

Utility Bill Type Electricity, Gas, Telephone, Water
Utility Bill Total Amount $952.85
Utility Bill Amount Paid
Heating Cooling Source Both
When did this information change?

School Enrollment Details - SALOME SHEBA

School enrollment status Full Time
Type of school attended College or University
Highest level of education successfully completed in the
school
Is this a federal or state funded work-study program
Name of school
Address Line1
Address Line2
City
State
Zip Code
Anticipated graduation date
When did this information change?

School Enrollment Details - SHUKURU KAHINDO

School enrollment status Not in school
Type of school attended
Highest level of education successfully completed in the
school

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Is this a federal or state funded work-study program
Name of school
Address Line1
Address Line2
City
State
Zip Code
Anticipated graduation date
When did this information change?

School Enrollment Details - EMMANUELLA GRABRIELLA

School enrollment status Not in school
Type of school attended
Highest level of education successfully completed in the
school
Is this a federal or state funded work-study program
Name of school
Address Line1
Address Line2
City
State
Zip Code
Anticipated graduation date
When did this information change?

School Enrollment Details - ESTA NEEMA

School enrollment status Full Time
Type of school attended High School
Highest level of education successfully completed in the
school
Is this a federal or state funded work-study program
Name of school
Address Line1
Address Line2
City
State
Zip Code
Anticipated graduation date
When did this information change?

Account Level Contact Information

Account Level Email Address [email protected]
Account Level Mobile Phone Number (404) 917-5330

Signing Your Application Details

Would you like to apply to register to vote where you live
No
now?
Renewal of Coverage in Future Years
Application T24532302 Rev(11/20) https://gateway.ga.gov/access/
Electronically Signed Yes
Signed By SALOME R SHEBA

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

 HIPAA Notice of Privacy Practices

Georgia Department of Human Services

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW THIS NOTICE CAREFULLY.

If you have any questions about this notice, please contact:

Georgia Department of Human Services

HIPAA Privacy Officer

[email protected]
(404) 657-9761 phone
(404) 657-1123 fax

The Department of Human Services (DHS) is an agency of the Executive Branch of Georgia
government charged with the administration of numerous federal programs responsible for the
storage, use and maintenance of medical and other confidential information. Federal and state
laws establish strict requirements for these programs regarding the use and disclosure of
confidential and protected information. DHS is required to comply with those laws as noted
throughout this Notice.

OBLIGATIONS OF THE DEPARTMENT OF HUMAN SERVICES:

DHS is required by law to:

• Maintain the privacy of protected health information;

• Give you this notice of our legal duties and privacy practices regarding health
information about you; and
• Follow the terms of our notice currently in effect.

HOW DHS MAY USE AND DISCLOSE HEALTH INFORMATION:

The following describes the ways DHS may use and disclose health information that identifies
you ("Health Information"). Except for the purposes described below, DHS will use and disclose
Health Information only with your written permission. You may revoke such permission at any
time by writing to the HIPAA Privacy Officer at the contact information above.

For Treatment. DHS may use and disclose Health Information for your treatment and to provide
you with treatment-related health care services. For example, DHS may disclose Health
Information to doctors, nurses, technicians, or other personnel who are involved in your medical
care and need the information to provide you with medical care.

For Payment. DHS may use and disclose Health Information so that DHS or others may bill
and receive payment related to your care, an insurance company, or a third party for the
treatment and services you received. For example, DHS may provide your health plan
information so that treatment may be paid for.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

For Health Care Operations. DHS may use and disclose Health Information for health care
operations purposes. These uses and disclosures are necessary to make sure that quality care
is received and to operate, manage, and administer the functions of the agency. For example,
DHS may use and disclose information to make sure the medical care you receive is of the
highest quality. DHS also may share information with other entities that have a relationship with
you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and

Services. DHS may use and disclose Health Information to contact you to remind you of an
appointment with a physician. DHS also may use and disclose Health Information to tell you
about treatment alternatives or health-related benefits and services that may be of interest to
you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, DHS may
share Health Information with a person who is involved in your medical care or payment for your
care, such as your family or a close friend. DHS also may notify your family about your location
or general condition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, DHS may use and disclose Health Information for
research. For example, a research project may involve comparing the health of patients who
received one treatment to those who received another, for the same condition. Before DHS
uses or discloses Health Information for research, the project will go through a special approval
process. Even without special approval, DHS may permit researchers to look at records to help
them identify patients who may be included in their research project or for other similar
purposes, as long as they do not remove or take a copy of any Health Information.

SPECIAL SITUATIONS:

As Required by Law. DHS will disclose Health Information when required to do so by

international, federal, state or local law.

To Avert a Serious Threat to Health or Safety . DHS may use and disclose Health Information
when necessary to prevent a serious threat to your health and safety or the health and safety of
the public or another person. Disclosures, however, will be made only to someone who may be
able to help prevent the threat.

Business Associates. DHS may disclose Health Information to our business associates that
perform functions on our behalf or provide us with services if the information is necessary for
such functions or services. For example, DHS may utilize the services of a separate entity to
perform billing services. All DHS business associates are obligated to protect the privacy of your
information and are not allowed to use or disclose any information other than as specified in our
contract.

Organ and Tissue Donation. If you are an organ donor, DHS may use or release Health
Information to organizations that handle organ procurement or other entities engaged in
procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or
tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, DHS may release Health
Information as required by military command authorities. DHS also may release Health
Information to the appropriate foreign military authority if you are a member of a foreign military.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Workers Compensation. DHS may release Health Information for workers compensation or
similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. DHS may disclose Health Information for public health activities. These
activities generally include disclosures to prevent or control disease, injury or disability; report
births and deaths; report child abuse or neglect; report reactions to medications or problems
with products; notify people of recalls of products they may be using; a person who may have
been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
and the appropriate government authority if it is believed a patient has been the victim of abuse,
neglect or domestic violence. DHS will only make this disclosure if you agree or when required
or authorized by law.

Health Oversight Activities. DHS may disclose Health Information to a health oversight
agency for activities authorized by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are necessary for the government to
monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. DHS may use or disclose your Protected Health
Information to provide legally required notices of unauthorized access to or disclosure of your
health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, DHS may disclose Health
Information in response to a court or administrative order. DHS also may disclose Health
Information in response to a subpoena, discovery request, or other lawful process by someone
else involved in the dispute, but only if efforts have been made to tell you about the request or to
obtain an order protecting the information requested.

Law Enforcement. DHS may release Health Information if asked by a law enforcement official
if the information is: (1) in response to a court order, subpoena, warrant, summons or similar
process; (2) limited information to identify or locate a suspect, fugitive, material witness, or
missing person; (3) about the victim of a crime even if, under certain very limited circumstances,
we are unable to obtain the person's agreement; (4) about a death we believe may be the result
of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to
report a crime, the location of the crime or victims, or the identity, description or location of the
person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. DHS may release Health Information
to a coroner or medical examiner. This may be necessary, for example, to identify a deceased
person or determine the cause of death. DHS also may release Health Information to funeral
directors as necessary for their duties.

National Security and Intelligence Activities. DHS may release Health Information to
authorized federal officials for intelligence, counter-intelligence, and other national security
activities authorized by law.

Protective Services for the President and Others. DHS may disclose Health Information to
authorized federal officials so they may provide protection to the President, other authorized
persons or foreign heads of state or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under

the custody of a law enforcement official, DHS may release Health Information to the

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

correctional institution or law enforcement official. This release would be if necessary: (1) for the
institution to provide you with health care; (2) to protect your health and safety or the health and
safety of others; or (3) the safety and security of the correctional institution.

USES AND DISCLOSURES THAT REQUIRE DHS TO PROVIDE YOU AN OPPORTUNITY

TO OBJECT AND OPT

Individuals Involved in Your Care or Payment for Your Care. Unless you object, DHS may
disclose to a member of your family, a relative, a close friend or any other person you identify,
your Protected Health Information that directly relates to that person's involvement in your
health care. If you are unable to agree or object to such a disclosure, DHS may disclose such
information as necessary if it is determined that it is in your best interest based on the
professional judgment of DHS.

Disaster Relief. DHS may disclose your Protected Health Information to disaster relief
organizations that seek your Protected Health Information to coordinate your care, or notify
family and friends of your location or condition in a disaster. DHS will provide you with an
opportunity to agree or object to such a disclosure whenever it is practical to do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your Protected Health Information will be made only with
your written authorization:

1. Uses and disclosures of Protected Health Information for marketing purposes; and

2. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the
laws that apply to DHS will be made only with your written authorization. If you do provide DHS
an authorization, you may revoke it at any time by submitting a written revocation to the above-
referenced Privacy Officer. Upon receipt, DHS will no longer disclose Protected Health
Information under the authorization. However, disclosures made in reliance upon your
authorization before you revoked it will not be affected by the revocation.

YOUR RIGHTS:

You have the following rights regarding Health Information DHS has about you:
Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to
make decisions about your care or payment for your care. This includes medical and billing records, other
than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in
writing, to the above referenced HIPAA Privacy Officer. DHS has up to 30 days to make your Protected
Health Information available to you and DHS may charge you a reasonable fee for the costs of copying,
mailing or other supplies associated with your request. DHS may not charge you a fee if you need the
information for a claim for benefits under the Social Security Act or any other state of federal needs-based
benefit program. DHS may deny your request in certain limited circumstances. If DHS does deny your
request, you have the right to have the denial reviewed by a licensed healthcare professional who was not
directly involved in the denial of your request, and DHS will comply with the outcome of the review.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is
maintained in an electronic format (known as an electronic medical record or an electronic health record),
you have the right to request that an electronic copy of your record be given to you or transmitted to
another individual or entity. DHS will make every effort to provide access to your Protected Health
Information in the form or format you request, if it is readily producible in such form or format. If the
Protected Health Information is not readily producible in the form or format you request, your record will be
provided in either our standard electronic format. If you do not want this form or format, a readable hard
copy form will be provided. DHS may charge you a reasonable, cost-based fee for the labor associated
with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured
Protected Health Information.

Right to Amend. If you feel that Health Information DHS has is incorrect or incomplete, you may request
DHS to amend the information. You have the right to request an amendment for as long as the information
is kept by or for our office. To request an amendment, you must make your request, in writing, to the
above-referenced HIPAA Privacy Officer.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures DHS made
of Health Information for purposes other than treatment, payment and health care operations or for which
you provided written authorization. To request an accounting of disclosures, you must make your request,
in writing, to the above-referenced HIPAA Privacy Officer.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health
Information DHS uses or disclosed for treatment, payment, or health care operations. You also have the
right to request a limit on the Health Information DHS discloses to someone involved in your care or the
payment for your care, like a family member or friend. For example, you could ask that DHS not share
information about a particular diagnosis or treatment with your spouse. To request a restriction, you must
make your request, in writing, to the above-referenced HIPAA Privacy Officer. DHS is not required to agree
to your request unless you are requesting DHS restrict the use and disclosure of your Protected Health
Information to a health plan for payment or health care operation purposes and such information you wish
to restrict pertains solely to a health care item or service for which you have paid ‘out-of-pocket’ in full. If
DHS agrees, we will comply with your request unless the information is needed to provide you with
emergency treatment.

Right to Request Confidential Communications. You have the right to request that DHS communicate with
you about medical matters in a certain way or at a certain location. For example, you can ask that DHS
only contact you by mail or at work. To request confidential communications, you must make your request,
in writing, to the above-referenced HIPAA Privacy Officer. Your request must specify how or where you
wish to be contacted. DHS will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may request a
copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still
entitled to a paper copy of this notice. To obtain a paper copy of this notice, please contact the above-
referenced HIPAA Privacy Officer.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

CHANGES TO THIS NOTICE:

DHS reserves the right to change this notice and make the new notice apply to Health
Information already obtained as well as any information received in the future. DHS will post a
copy of the current notice at our office. The notice will contain the effective date on the first
page, in the top right-hand corner.

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint, in writing, by
contacting the above-referenced HIPAA Privacy Officer. You will not be penalized for filing a
complaint.

You may also file with the Secretary of the Department of Health and Human Services. For
more information on HIPAA privacy requirements, HIPAA electronic transactions and code sets
regulations and the proposed HIPAA security rules, please visit ACOG s web site,
http://www.acog.org or call (202) 863-2584.

NON-DISCRIMINATION:

This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age,
sex and in some cases religion or political beliefs.

The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex,
religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any
program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g.
Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local)
where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may
contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information
may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint
Form, (AD-3027), found online at: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-
complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the
information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit
your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410

(2) fax: (202) 690-7442; or

(3) email: [email protected].

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues,
persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in
Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by
State); found online at:
http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

To file a complaint of discrimination regarding a program receiving Federal financial assistance through
the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights,
Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (800) 368-1019 (voice) or
(800) 537-7697 (TTY).

This institution is an equal opportunity provider.

You may also file a complaint of discrimination by contacting the DFCS Civil Rights Program, Two
Peachtree Street, N.W., Suite 19-248, Atlanta, Georgia 30303 or call (404) 657-3735 or fax (404)
463-3978. For limited English proficient and sensory impaired services, contact the DHS Limited English
Proficiency and Sensory Impaired Program at: Two Peachtree Street, N.W., Suite 29-103 N.W., Atlanta,
GA 30303 or call (404)-657-5244 or fax (404)-651-6815.

Under the Department of Community Health (DCH) policy, Medicaid cannot deny you eligibility or
benefits based on your race, age, sex, disability, national origin, or political or religious beliefs. To report
Medicaid eligibility or provider discrimination, call the Georgia Department of Community Health’s Office
of Program Integrity (local 404-463-7590) (toll free) 800-533-0686.

Electronic Signature

I understand that an electronic signature has the same legal effect and can be enforced in the
same way as a written signature.

I have read, understand, and acknowledge receipt of the DHS HIPAA Notice of Privacy
Practices

Electronically Signed Yes

Signed By SALOME R SHEBA

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

In all programs, you have the right to:

• Request assistance filling out this form and free language assistance services (interpreters, translated materials, or
direct in-language services) if you have trouble reading, writing, speaking or understanding the English language.
• Request auxiliary aids and services and reasonable modifications if you or someone in your household has a
disability.
• Decide if you want to provide information about your race and ethnicity. We collect data on race, color, and national
origin solely for the purpose of determining the State's compliance with Federal civil rights laws, and your response will
not affect consideration of your application, and may be protected by the Privacy Act. By providing this information,
you will assist us in assuring that this program is administered in a nondiscriminatory manner. Your household is not
required to give us this information and it will not affect your eligibility or benefit level.
• Request a fair hearing in writing or in person. You have the right to be represented by a household member, legal
counsel, a relative, a friend or other spokesperson. If you are not satisfied with the action we have taken on your case,
you can request a hearing by contacting the county office where you applied for benefits or by calling 1-877- 423-4746.
• Review some of the material and information in your case file. However, you may not be able to see all of the
information in the case file, such as names of people who have given us information about you or your household
members or information about any criminal prosecutions involving you or any of your household members.

In all programs, you are responsible for:

• Giving your worker correct information and providing proof of statements needed to receive benefits. When you sign
this form, you are giving your worker permission to get information from your employer, bank, neighbor or others so we
can make sure you are receiving the correct amount of benefits.
• Telling the truth at all times. If you or someone who is applying for you provides incorrect information, you may be
committing a crime, and you may go to jail.
• Providing proof that you or anyone in your household applying for benefits is a U.S. citizen or eligible immigrant. Note:
Your worker will give you a list of the ways you can prove your citizenship or immigration status. WIC does not require
citizenship or immigration status to determine your eligibility for the program. For Child Care, you are responsible for
providing proof that any child applying for benefits is a U.S. citizen or qualified alien.
• Reporting certain changes in your household situation. Each program has different reporting requirements. See the
responsibilities section for each program for things you need to report.

Food Stamps (SNAP) Rights and Responsibilities

Please read the following information carefully.

YOU HAVE THE RIGHT TO

• Receive an application on the day you ask for it.
• Have your application accepted when you file it.
• Have an adult apply for your household if you are unable to.
• A telephone interview.
• Receive fair treatment without regard to age, sex, race, color, handicap, religious creed, national origin, or political
beliefs.
• Have a fair hearing if you disagree with any action on your case.
• Examine your case file and the rules of the program.
• Be notified in advance if your benefits are reduced or stopped due to a change that is not reported in writing.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

YOUR RESPONSIBILITIES:

• You must answer all questions completely.

• You must sign your name to certify, under penalty of perjury, that all answers are true.
• You must provide proof that you are eligible.
• You must report when your total gross monthly income goes over the income limit for your household size. You must
report this change no later than the 10th day from the end of the month in which the change occurred. If you are a
single working adult with no children, you must also report When your work hours fall below 20 hours a week or 80
hours per month.
• You must report when your household receives substantial lottery and gambling winnings. This is a cash prize won in
a single game. If you or a household member receives lottery or gambling winnings, gross amount of $3500 or more
(before taxes or other amounts are withheld), you must report these winnings within 10 days of the end of the month in
which the household received the winnings.
• Do not give false information or hide information to get benefits that your household should not get.
• Do not sell, trade, or give away your food stamp benefits.
• Use food stamp benefits to buy only eligible items.
• Food Stamps (SNAP) households CAN NOT use their benefits to purchase non-food items such as beer, Wine, liquor,
cigarettes, tobacco, pet foods, soaps, paper products and household supplies. Food Stamps (SNAP) households also
ARE NOT allowed to purchase food on credit with their benefits.

PENALTIES:

• Any household member who breaks any of the food stamps (SNAP) rules on purpose can be barred from the Food
Stamp Program for one year to permanently, fined up to $250,000, imprisoned up to 20 years or both. She/he may
also be subject to prosecution under other applicable Federal and State laws. She/he may also be barred from the
Food Stamp Program for an additional 18 months if court ordered.
• Any household member who intentionally breaks the rules may not get Food Stamps (SNAP) for one year for the first
offense, two years for the second offense, and permanently for the third offense.
• If a court of law finds you or any household member guilty of using or receiving Food Stamps (SNAP) benefits in a
transaction involving the sale of a controlled substance, you or that household member will not be eligible for benefits
for two years for the first offense, and permanently for the second offense.
• If a court of law finds you or any household member guilty of having used or received benefits in a transaction
involving the sale of firearms, ammunition, or explosives, you or that household member will be permanently ineligible
to participate in the Food Stamps (SNAP) Program upon the first offense of this violation.
• If a court of law finds you or any household member guilty of having trafficked benefits for an aggregate amount of
$500 or more, you or that household member will be permanently ineligible to participate in the Food Stamps (SNAP)
Program upon the first offense of this violation.
• If you or any household member is found to have given a fraudulent statement or representation with respect to
identity (who they are) or place of residence (where they live) in order to receive multiple Food Stamp benefits, you or
that household member will be ineligible to participate in the Food Stamps (SNAP) Program for a period of 10 years.
• For more information about Community Outreach Services, please visit our website at:
http://www.dfcs.dhs.georgia.gov or call 1-877-423-4746

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Individuals who are applying for public assistance must provide or apply for an SSN, and/or verify their citizenship or
immigration status. Some immigrants are eligible and some are not, depending on their legal status. If you or anyone in
your household does not have an SSN, we can help you apply for one. Applying for an SSN will not delay a decision on
your application for benefits. An individual, who is not applying for public assistance and who does not provide an SSN,
citizenship or immigrant status may be designated as a non-applicant.
A non-applicant is not required to provide an SSN, citizenship, or immigrant status but is required to provide other
information that may affect the eligibility of other applicant household members such as income or resources. A non-
applicant is not eligible to receive benefits. Only the people who give information to us about their SSN, citizenship, or
immigration status will be eligible to receive benefits. We will use this information to check the Income and Eligibility
Verification System (IEVS). We will also match your information with other Federal, state, and local agencies to verify your
income and eligibility. This information may also be given to law enforcement officials to use to catch people who are
running from the law. If your household has a Food Stamp claim, the information on this application, including SSNs, may
be given to Federal and State agencies and private claims collection agencies for them to use in collecting the claim. We
will not share your information with the United States Citizenship and Immigration Services (USCIS); however, if
immigration status information has been submitted on your application, this information may be subject to verification
through USCIS and may affect your household’s eligibility and benefit level. We will not deny benefits to applicant
household members because other household members fail to provide their SSN, citizenship, or immigration status.
Applying for or receiving Food Stamp benefits does not make a non-citizen a public charge. Receiving or accepting
Supplemental Security Income (SSI), TANF cash assistance, Institutionalized Long Term Care Medicaid, or state General
Assistance could make a non-citizen a public charge if all eligibility criteria are met. However, receiving these benefits
does not automatically make an individual inadmissible or ineligible to adjust his/her status to lawful permanent resident
on a public charge basis. A “public charge” means you are a person who is likely to become “primarily dependent” on the
government to maintain your way of life, as demonstrated by either the receipt of public cash assistance for income
maintenance or by institutionalization for long-term care at the government’s expense.” If you are considered to be a
public charge, you will not be deported, or denied permanent status because you have applied for or receive public
assistance. Emergency Medicaid, including labor and delivery, is available for pregnant non-qualified and undocumented
immigrants.
• decide if you want to provide information about your race and ethnicity. We collect data on
race color, and national origin to ensure we are in compliance with Federal civil rights laws. By providing this information,
you will assist us in administering our programs in a non- discriminatory manner. Your household is not required to give us
this information and it will not affect your eligibility or benefit level.

Benefits of Child Support Services

The Division of Child Support Services (DCSS) may be able to provide the following benefits:

• finding the absent parent

• legally establishing your child's paternity
• receipt of child support payments that may give you more money than if you receive TANF
• acquisition of private health insurance through the absent parent, and
• acquisition of rights of future Social Security, veterans or other government benefits

Cooperation with DFCS and DCSS

The law requires you to help the Division of Family and Children Services (DFCS) and the Division of Child Support
Services (DCSS) get any support owed to you and the children for whom TANF is requested, unless you have good
cause for not helping.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

In helping DFCS or DCSS, you must do one or more of the following:

• Name the absent parent of any child for whom you are requesting TANF and/or Medicaid.
• Provide information to help find the absent parent.
• Help determine who the legal father is if your child was born out of wedlock.
• Agree to have a DNA test if the person you name as the father denies paternity.
• Help the state get money owed to you and/or the child who receives TANF.
• Provide information about medical insurance the absent parent has on your child.

You must come to the DFCS office, DCSS or court to sign papers or provide needed information.

Good Cause

You may have good cause for not wanting to help DCSS collect child support or medical coverage for your child. You may
not have to help if you believe helping is not in your child's best interest, and if you can prove it. If you want to claim good
cause, you must tell your worker. You can do this at any time.

If You Do Not Help and Do Not Have Good Cause

• You will not be eligible to receive TANF for yourself and your child.
• You will not be eligible for Medicaid but your child may still be eligible. Good Cause Reasons

You may claim good cause for any of the following reasons:

• Your help may cause serious physical or emotional harm to your child or to you.
• The child was born as a result of rape or incest.
• Court proceedings are underway for adoption of the child.
• An agency is helping you to decide whether to place the child for adoption.

To Prove Good Cause, You Must

• give DFCS information it needs to decide if you have good cause for not helping. If you fear physical harm and cannot
get proof, DFCS may sill be able to make a good cause determination.
• give proof to DFCS within 20 days of claiming good cause. DFCS will give you more time only if you have trouble
getting proof.

DFCS may excuse you from helping based on the information you provide. Or, DFCS may ask you to provide more
information. DFCS will not contact the absent parent without telling you.

NOTE: If you are applying for TANF, you will not be approved until you give DFCS proof of your claim of good cause or
the information DFCS needs to investigate your claim.
Examples of Proof Of Good Cause

• birth certificate, medical or law enforcement records showing that the child was born as a result of rape or incest
• court or other legal documents showing that adoption proceedings have begun
• court, medical, criminal, child protective services, psychological or law enforcement records showing that the absent
parent may hurt you or the child
• medical records or written statements from a mental health professional showing the history and current status of your
and/or the child's emotional health
• a written statement from a public or private agency showing you are being helped to decide whether to give your child
up for adoption
• sworn statements from friends, neighbors, clergy, social workers, or medical professionals who know why you have
good cause

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

If you need help in getting any of the documents, ask your worker.

Child Support Rules

If you receive TANF, you give the state of Georgia, by law, any rights you have to receive child support. Once the court
order is established, the absent parent will be required to pay child support through DCSS. After the court order is
established, you will be required to report any money you receive directly from the absent parent. You must also help
establish paternity for your child and cooperate and do not have good cause, you may not be eligible for TANF.

If you receive TANF and the absent pays child support through the Division of Child Support Services (DCSS), you
probably will NOT receive the full amount of the child support payment. Instead you may receive a ""gap"" payment. All
child support paid by an absent parent, which is in access of the ""gap"" amount, is retained by DCSS and is used to pay
back the TANF funds that you have received. Your TANF case manager can explain gap budgeting and the payment
procedures to you.

If your TANF case is closed, child support payments will be sent to you up to the amount of the absent parent's current
monthly obligation. Any child support amount paid over the current obligation will be kept by the state to repay past TANF
grants received by you. Once the past TANF grants are repaid, you will be sent all child support paid by the absent parent.

If your TANF case is closed and then reopened, any child support back payments due you will be assigned to the State up
to the amount of all TANF money you will have ever received. When the Unreimbursed Public Assistance (UPA) is repaid,
then you will start receiving any back payments owed to you.

If you receive child support payments to which you are not entitled, you may have to repay the state. The state will notify
you of the amount of the overpayment and the timeframe for repayment.

DCSS may review the DFCS good cause decision in your case. If you request a hearing about the decision, DCSS may
participate in the hearing.

If you have a good cause for not helping, DCSS will not try to establish paternity or collect child support.
Consent to Exchange Information

I understand that different state agencies provide different services and benefits. Each agency must have specific
information to determine eligibility services and benefits. I understand that the Department of Human Services can
disclose certain Information about me to other state agencies, including information in electronic databases, for the
purpose of determining my eligibility for benefits/services provided by that agency. This disclosure will make it easier for
agencies to work together efficiently to provide or coordinate services and benefits. Agencies include, but are not limited
to, the Department of Public Health, the Department for the Aging, the Department of Rehabilitative Services and the
Department of Vocational Rehabilitation."

The state statute that provides the legal basis for safeguarding the confidentiality of assistance- related information is the
Official Code of Georgia Annotated 49-4-14. This statute restricts the use or disclosure of information concerning
applicants for or recipients of public assistance to purposes directly connected to the administration of public assistance.

In addition, various Federal regulations specifically forbid the release of TANF Program information to unauthorized
persons or agency representatives.

All case record material is confidential, including names and addresses of applicants and recipients (A/R), as well as the
types and amounts of benefits provided.

Interviews should be conducted in a confidential setting.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

Records, information and communication of the Division, including county Departments of Family and Children Services,
that identify applicants for, or recipients of, cash assistance under the TANF program, are confidential and are not
considered public records.

The disclosure of information concerning applicants and recipients is limited to purposes directly connected with the
administration of the TANF Division, and to the administration of other federal assistance programs and federally assisted
state programs which provide assistance on a means-tested basis to low-income individuals/families.

These programs include:

• Food Stamps
• Child Support
• IV-E Foster Care
• Adoption Assistance
• SSI
• Medicaid
• Office of Inspector General-Benefits Recovery Unit
• Human Services
• Social Security Administration
• IEVS, and,
• the General Office of the U.S.

The purpose of disclosing the client's information to other programs is establishing eligibility, determining the amount of
benefits and providing services to the applicants and/or recipients. Information used solely for these purposes can be
released without the consent of the applicant or recipient.

Childcare and Parent Services (CAPS) is a federally funded statewide program that assists families that meet program
requirements to obtain and sustain self-sufficiency by subsidizing a portion of the cost of child care. The program is
administered at the state level by staff at Bright from the Start: Georgia Department of Early Care and Learning (DECAL).

This notice describes how medical information about you may be used and disclosed, and how you can get access to this
information. Please review it carefully.

PEACHCARE FOR KIDS PRIVACY PROMISE TO YOU

We in the Georgia Department of Community Health (DCH) understand that health information about you and your family
is private. We will protect your information. This notice tells you about your information privacy rights in the PeachCare for
Kids program.

The privacy practices described in this notice will be effective August 29, 2003.

By law, PeachCare for Kids must use and disclose your child’s medical information to provide information:
To you or to someone who has the legal right to act for you or your child

• To the Secretary of the U.S. Department of Health and Human Services, if necessary
• Where required by law

YOUR MEDICAL INFORMATION RIGHTS

You have the following rights about your child’s medical information: (Note: These rights may be limited by Georgia law or
by court orders.)

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

• You have the right to see and have a copy of your child’s health information held by PeachCare for Kids. Exceptions
are psychotherapy notes and information that is needed for a legal action relating to DCH.
• You have the right to ask DCH to correct your child’s medical information if you think that it is wrong. DCH may deny
your request in some cases.
• You have the right to ask for a copy of disclosures that DCH has made of your child’s medical information starting in
April 2003. The list would not include disclosures to you or to your personal representative, or for payment for your
child’s health care, or for PeachCare for Kids administration.
• You have the right to ask for restrictions on some uses or disclosures of your child’s health information. DCH is not
required to meet your request.
• You have the right to ask for DCH to contact you about your child’s health in a way or at a place that will help you keep
your child’s information private.
• You have the right to a paper copy of this notice. You may ask for another copy of this notice, or you may get a copy
from DCH’s Web site, www.dch.ga.gov.

PRIVACY LAW’S REQUIREMENTS

DCH is required by law to:

• Maintain the privacy of your child’s medical information

• Give you this notice of DCH¿s legal duties and privacy practices
• Follow the terms of this notice
• Not use or disclose your child’s medical information without your written authorization, except for the reasons in this
notice. You may take away your authorization in writing at any time, except for information that was already disclosed

DCH may change its privacy practices. We will provide a new notice to you if there is a material change in its privacy
practices. We will post the new notice on the DCH Web site at www.dch.ga.gov.

HOW DCH USES AND DISCLOSES HEALTH CARE INFORMATION

PeachCare for Kids contracts with other agencies and some private companies. We may disclose some or all of your
child’s information to the other agency or company so that they can do the job we have asked them to do. To protect your
child’s information, PeachCare for Kids requires the other agency or company to safeguard the information.

Below are ways that we may use and disclose your child’s health information:

For Payment: We may use and disclose information about your child so that we can pay for the child’s health care. When
your child receives medical care, the child’s health care provider sends a claim to PeachCare for Kids for payment. The
claim includes information that identifies your child, as well as your child’s diagnoses and treatments.

For Medical Treatment: We may use or disclose information about your child to ensure that she or he receives needed
medical care. We may send you reminders of medical appointments.

To Operate the PeachCare for Kids Program: We may use or disclose information about your child to manage the
PeachCare for Kids program and be sure that your child receives quality care. We may contract with a company that
reviews health records to check on the quality of your child’s care.
To Keep You Informed: We may mail information to you about your child’s health. Examples are information about
managing a disease and appointment reminders.

For Overseeing Health Care Providers: We may disclose information about you to the government agencies that license
and inspect medical facilities, such as hospitals.

As Required by Law: We will disclose information about your child when required by law or by court order.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/

For more information or to report a privacy problem

If you have questions about your child’s health or health care services, you should contact your child’s health care
provider (doctor, hospital, or others).
If you believe your child’s privacy rights have been violated:

• You may file a complaint with PeachCare for Kids by calling the Member Inquiry Unit at 1-866- 211-0950
• You may file a complaint with the Health and Human Services Office for Civil Rights by writing to:

U.S. Department of Health & HumanServices

Office for Civil Rights, Region IV
61 Forsyth Street SW, Suite 3B70
Atlanta, GA 30303-8909

There will be no retaliation for filing a complaint.

Application T24532302 Rev(11/20) https://gateway.ga.gov/access/