Written by a parent, not a doctor. Nothing here is medical advice.

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Georgia Department of Public Health

Children’s Medical Services

What you get

Help arranging specialty care, equipment, travel, interpreters, appointments, and payment sources for your child. Open now.

Who starts it
You, with a document from your doctor
How it’s sent
PDF form, sent the way they ask
Your time
An hour or so, plus waiting for the document
Last checked
Aug 27, 2026

Before you start, check you fit

  • Your child is 20 or under.
  • Get written approval before a service if the program requires it.
  • Prior written approval may be required before CMS pays for services.

  1. Ask your doctor for the documentStart here. This is the part that takes the longest.

    Georgia Department of Public Health needs 2 things from your doctor. Copy this message, or say it in person at the next visit.

    Hi [doctor’s name],

We’d like to apply to Georgia Department of Public Health’s Children’s Medical Services. Help arranging specialty care, equipment, travel, interpreters, appointments, and payment sources for our child. They are taking applications now.

They need 2 things from you: a note confirming the diagnosis and a note confirming the diagnosis. Their form and instructions are here: https://dph.georgia.gov/CMS

Could you do that when you have a chance? I’ll bring the printed form to our next visit, or I can email it. Thank you for everything you do for us.

[your name] · [phone]
    Copying is the only thing this page does with your text. Nothing is saved.

  2. Fill in their formPrint it, or fill it in on screen if the PDF allows.

    Open the application PDF ↗ Checked Aug 27, 2026

    What the form asks for

    Referral contact information
    Referring Person/PracticePhoneFaxEmailIs the parent or guardian aware of this referral
    Child information
    Child’s First NameChild’s Last NameChild’s Date of BirthChild’s SexBirth Mother’s First and Last NameBirth Mother’s Date of Birth (If known)Child’s Race (Select all that apply)OtherChild’s EthnicityOtherChild’s Insurance (If known)Insurance Policy # (if known)Child’s Primary Medical Provider Name and Phone Number (If known)
    Show the rest of the form (2 more sections)
    Parent/guardian contact information
    Guardian First and Last NameRelationship to ChildPhone NumberAlternative Phone NumberEmailStreet AddressCityStateZip CodeCounty (If known)Primary LanguageOtherInterpreter NeededDFCS Case Worker Name and Phone Number (If applicable)
    Reason(s) for referral
    Confirmed diagnosis. Child has a diagnosed condition that impacts development and/or is a chronic medical conditionDiagnosis and ICD-10 Code (Attach diagnostic report)Suspected developmental delay or diagnosis. Child may have a developmental delay. Screening or evaluation is neededSelect all that applyHas child received a recent screeningAt risk for developmental delay. Child has medical, social, or environmental risk factors and may benefit from screeningSelect all that applyOtherComments

  3. Send it the way they ask

    • Send the completed Child Health Referral Form to the local Child Health Referral Contact, or call the local contact and complete the referral form by phone.

After you send

DPH does not publish a receipt-confirmation method or response deadline; retain a copy and ask the local Child Health Referral Contact how to confirm receipt. If you have not heard back in two weeks, write and ask whether it arrived.

Full record, as published