SNAP

Hosea Helps has Benefits

Take the time to invest in yourself.

Completing this form could mean financial assistance for your household.

Supplemental Nutrition Assistance Program

WIC

Women, Infants and Children

CAPS

Child and Parent Services

TANF

Temporary Assistance for Needy Families

GRG

Grandparents Raising Grandchildren

MEDICAID

Medical Assistance

Only complete this form if you want to see which of these benefits you or someone in your household might be eligible for. This form has two parts. You must complete both parts of this form.

Take the time. You're worth it.

Before you get started!

1. Have a picture of your Photo ID ready to upload.

2. Have key information for your household ready to enter.

3. You can apply for benefits for multiple members of your household.

Read, upload and sign to get started.

Human Services: SNAP Authorization Form

GA DHS: Georgia Gateway Transaction Authorization

Read the authorization form and sign the bottom to agree.

I hereby request and authorize Hosea Helps to aid me with, and to use any medical, health, or other protected health information that I disclose to its employees for the sole purpose of assisting me with, the following:

(1) GA Gateway Application for Food Stamps (SNAP), Medical Assistance (Medicaid), Temporary Assistance for Needy Families (TANF), Women, Infants and Children (WIC), and Child and Parent Services (CAPS).

(2) GA Gateway Application for Food Stamps (SNAP), Medical Assistance (Medicaid), Temporary Assistance for Needy Families (TANF), Women, Infants and Children (WIC), and Child and Parent Services (CAPS).

(3) GA Gateway Report a Change

(4) GA Gateway Request Closure for Food Stamps (SNAP), Medical Assistance (Medicaid), Temporary Assistance for Needy Families (TANF), Women, Infants and Children (WIC), and Child and Parent Services (CAPS).

I understand I will still be responsible for the acknowledgement and electronic signatures required. I will also submit the transaction on Georgia Gateway.

I understand that the federal Privacy Rule as defined by the Health Insurance Portability and Accountability Act (HIPAA) does not protect the privacy of information if redisclosed and therefore request that all information if obtained by this Service Site be held strictly confidential and not be further released. I further understand that my eligibility for benefits is not conditioned upon my provision of this authorization. I intend this document to be a valid authorization conforming to all requirements of the Privacy Rule and understand that my authorization is only in effect for this transaction.

I understand that if I was assisted in Creating a User ID and Password it is my responsibility to change it immediately to protect my confidential information and access to my account. I understand that the agency and/or person assisting me with this transaction may be contacted by a DHS employee regarding my personal circumstances and information submitted on the transaction. I understand that the agency and/or person assisting me with this transaction will be able to view all of my notices (not just the notices specific to the transaction) and receive notice of the outcome of the transaction that is being submitted today.
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.

Ga Gateway Transaction Authorization Form (Rev. 4.22)

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, 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: program.intake@usda.gov.

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.

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 (202) 619-0403 (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.

Applicant/recipient must receive a copy of this form.

Ga Gateway Transaction Authorization Form (Rev. 4.22)

Your Authorization

Your First Name

Your Last Name

Birth Month

Birth Day

Birth Year

Your Email Address: Enter Twice to Confirm

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Confirm Your Email Address: Enter Twice to Confirm

Upload Your Photo ID

Maximum file size: 516MB

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Applicant Tracking Fields (Print and Complete)

Gateway Tracking Number (T Number)

IESUC Number

Client ID Number for Renewal, Report a Change or Closure Request

Hosea Helps' Representative (Print and Sign)

Hosea Helps' Representative's Full Name

Hosea Helps' Representative's Signature

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