Trusts and Other Legal Documents

Any trust, such as a Special Needs Trust, Qualified Income Trust (QIT), Pooled Trust or other similar legal document is considered a TPL and is to be reported to DCH. Annotate Form 285 to indicate there is a trust document. Attach a copy of the trust or legal document and mail or email to the TPL Trust Unit.

If mailed, send the trust document (including QITs that adhere to a DCH approved format along with the QIT Certification form) and Form DMA 285, Health Insurance Information Questionnaire, to:

Georgia Department of Community Health ATTN: Trust Unit 100 Crescent Centre Pkwy, Suite 1000 Tucker, GA 30084 Email: gatrustunit@gainwelltechnologies.com Fax: 678-564-1169

Mail QITs that do not adhere to one of the DCH approved formats to:

Georgia Department of Community Health ATTN: Trust Unit 100 Crescent Centre Pkwy, Suite 1000 Tucker, GA 30084 Email: gatrustunit@gainwelltechnologies.com Fax: 678-564-1169

The Georgia Trust Unit is paperless and prefers all documents and information be emailed. For questions, email using the above address or call 678-564-1168.

Include Form 947 - QIT Approved Format Deviation Form , found in Appendix F - TOC ; explaining how the trust differs from the DCH approved QIT format and proof that a QIT account has been opened.

When the A/R with a trust/QIT dies or becomes ineligible, send the TPL Unit a copy of the original DMA 285. Annotate in red at the top of the form that the A/R is deceased/ineligible, the date of death/ineligibility, and whether the TPL is a trust or QIT.

Qualified Income Trust Fax: 678-564-1169 QIT email: gatrustunit@gainwelltechnologies.com

Special Needs Trusts Contact numbers: 678-564-1168; Fax: 678-564-1169 Special Needs Trust email: gatrustunit@gainwelltechnologies.com