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LETTER OF AGREEMENT For the Benefit of The Georgia Department of Community Health and the HospitalHospital Name: (the “Hospital “) As a Medicaid designated disproportionate share hospital provider,
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To fill out the DSH Letter of Agreement, follow these steps:
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Start by downloading the DSH Letter of Agreement form from the official website.
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Read the instructions and guidelines provided with the form carefully.
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Fill in your personal information, such as your name, contact details, and address.
05
Provide all the necessary information regarding the purpose and scope of the agreement.
06
Specify the terms and conditions that both parties agreed upon.
07
Review the completed form for accuracy and completeness.
08
Sign and date the form along with the counterpart who needs to sign.
09
Make a copy of the filled-out form for your records.
10
Submit the original signed agreement to the appropriate recipient as mentioned in the instructions.
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Await confirmation or further instructions regarding the acceptance of the agreement.
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- Organizations or individuals entering into a business partnership or collaboration.
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- Institutions or research bodies conducting joint studies or experiments.
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- Non-profit organizations seeking funding or grants.
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- Any party involved in a legal or official agreement that requires written documentation.
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