GCHEXS Account Registration

NEW FACILITIES: Complete the registration form below if your facility has never had a GCHEXS account, Once the form is submitted please allow 3-5 business days for a response of approval accompanied by your login credentials.

**There is no need to upload a document unless it is required.

STAFFING AGENCIES: Upload a copy of the contract between your company and the licensed Long Term Facility located in Georgia. Allow 10 to 15 business days to review the contract and validate the information provided.

Warnings:

* Provider Type:
Adult Day Centers Applicant Initiated Assisted Living Community/Personal Care Home Caregiver Registry DCH-OIG Contractors High Risk Providers Home Health Agency Hospice Intermediate Care Facility/Intellectually Disabled Long Term Care Hospital Moved DBHDD Jan26-Adult Residential Mental Health Moved DBHDD Jan26-Community Living Arrangement Moved DBHDD Jan26-Narcotics Treatment Program Nursing Home (NH) Private Home Care Provider Provider Facilitated SFC SNF/NF Dual Cert Structured Family Care Temporary Staffing Service

* Business 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:

Staffing agencies must provide documentation showing it has a formal contract with a qualified Long-Term Care (LTC) facility licensed by DCH.

* File Name:

* Description:

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