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Request to Fax Invoices


Request to Fax Invoices document sample

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									                                                                                                                                      2 Peachtree Street, NW
                                                                                                                                      Atlanta, GA 30303-3159
                   Rhonda M. Medows, MD, Commissioner                               Sonny Perdue, Governor                            www.dch.georgia.gov

                                                           Open Records Request
This form is to verify the requested information from the Georgia Department of Community Health, Division of Health
Planning. If you have any questions, please contact the following individuals:

Appointments/Filing Applications:                              Wendella McGaha (wmcgaha@dch.ga.gov)                    (404) 656-0409 or (404) 656-0442 fax
All requests/Database requests and updates:                    Jacqueline Wayman (jwayman@dch.ga.gov)                  (404) 656-0465 or (877) 592-9402 fax
Hearing Transcripts:                                           Fredia Bradford (fbradford@dch.ga.gov)                  (404) 656-0655 or (404) 656-0654 fax
Invoices:                                                      Kimberly Anderson (kanderson@dch.ga.gov)                (404) 657-4563 or (866) 509-6735 fax

Application Name:________________________________________________________________

File Number:____________________________________________________________________

Request made by:_____________________Phone No:________________ Date:_____________

           Certificate of Need:
           CON entire file                                                              DET entire file
           CON main application only                                                    DET request
           CON appendices                                                               DET decision only
           CON additional information                                                   LNR entire file
           CON completeness/incompleteness letter                                       LNR request
           CON decision only                                                            LNR decision only
           CON other: _______________________
           Database:                                                                               Need Projections
           Need Projection                                                                   Short-Stay Hospital ___________________
           Annual Hospital Questionnaire/Addenda Database                                     NICU – Level 2                         NICU – Level 3
           Annual Hospital Financial Survey Database                                           Inpatient Physical Rehab
           Annual Hospital Financial Survey Database (Historical)                               Ambulatory Surgery
           Annual Service-Specific Indigent/Charity Care Survey Database                         Skilled Nursing Facilities
           Annual Free-Standing Ambulatory Surgery Center Survey Database                         Home Health
           Annual Nursing Home Questionnaire Database                                              Cardiac Cath
           Annual Home Health Agency Survey Database                                                LTCH
           Annual Cardiac Catheterization Services Survey Database                                   Radiation Therapy
           Annual Open Heart Surgery Services Survey Database                                         Personal Care (above 24 beds)
           Radiation Therapy Services Survey Database                                                  PET
           Personal Care Home Survey Database                                                           Obstetrical
           Annual Positron Emission Tomography (PET) Services Survey Database                            TBI
           Pre 1998 Survey History Databases (If Available)
           Resident Population Projections Database for 2000-2015 (4/06 Release)
           Hospital Marketshare Databases (Each Year from 1999 to 2004) – Contain hospital discharge data, requires signed data agreement.
           CON other: ___________________________________________________________________________

Total cost:________________________________________ ** See price list and fee structure
       Preference of Delivery:
                 Pick-up/Courier _________________________________________________
                  US Postal Mail __________________________________________________
                   Mailing address:_________________________________________________
                    FedEx/DHL/UPS: _______________________________________________
                                                                                      (account number)

                                                                         Equal Opportunity Employer

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