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2023-188
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2023-188
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Last modified
10/9/2023 11:36:28 AM
Creation date
10/9/2023 11:35:54 AM
Metadata
Fields
Template:
Official Documents
Official Document Type
Agreement
Approved Date
09/29/2023
Control Number
2023-188
Agenda Item Number
Signed by County Administrator
Entity Name
State of Florida Agency for Health Care Administration
Subject
Letter of Agreement for Public Emergency Medical Transportation
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If yes, please list the provider and payment amount. <br />F'roviaer Name runaing oource HmounL <br />d. Does any portion of the provider donation constitute as a "bona fide donation" pursuant to 42 CFR <br />§ 433.54? 42 CFR § 433.54 requires donations will not be returned to the individual provider, the <br />provider class, or related entity under a hold harmless provision. <br />e. Is there an agreement between the IGT provider and the health care entity? If so, please specify <br />whether the agreement is written and provide the details. <br />7. Were funds utilized for the IGT specifically appropriated by the organization's board? <br />If yes, provide the board minutes and date of the appropriation. <br />I certify that the statements and information contained <br />in this submittal are true, accurate, and complete. <br />STATE OF FLORIDA <br />INDIAN RIVER COUNTY <br />THIS IS TO CERTIFY THAT THIS IS A <br />TRUE AND CORRECT COPY OF THE <br />ORIGINAL ON FILE IN THIS OFFICE. <br />kyr RYMI L DALER aERK <br />B y <br />P; C K <br />DATE I[� <br />ignature bf Officer or <br />Admrinistrator <br />Title <br />Date <br />
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