HomeMy WebLinkAboutCertified Indigent Care Agreement
Augusta Richmond GA
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DOCUMENT TYPE: .A ~ Yee I'I'leYlT
YEAR: ~tJ
BOX NUMBER: q
FILE NUMBER: 14Lo <60
NUMBER OF PAGES:
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AUGUSTA-RICHMOND COUNTY CERTIFIED INDIGENT CARE AGREEMENT
This Agreement is effective the 1st day of January, 2000, by and between Augusta,
Georgia, acting by and through the Augusta-Richmond County Commission (hereinafter referred
to as the "County") and University Health Services, Inc. d/b/a University Hospital (hereinafter
referred to as "University"), upon the terms and conditions set forth below.
WIT"NE S SETH:
WHEREAS, County and University have contracted for over thirty years for the
provision of certain health care servi~es to the indigent residents of Richmond County, Georgia;
and
WHEREAS, County and University desire to contract for the provision of certain health
care services to the certified indigent residents of Richmond County for calendar year 2000;
NOW, THEREFORE, for and in consideration of the promises and covenants contained
herein, and for other good and valuable consideration, the receipt and sufficiency of which is
hereby acknowledged, the parties hereto, intending to be legally bound, do hereby agree as
follows.
SECTION I. TERM OF AGREEMENT
This Agreement shall be for a term beginning January 1, 2000 and continuing until the
t~rmination date provided by this Agreement of December 31, 2000.
SECTION II. PROVISION OF HEALTH CARE SERVICES TO CERTIFIED
INDIGENTS; PAYMENTS BY COUNTY
County and University. agree to the following terms and conditions for the providing of
certain Covered Health Care Services to the certified indigent residents of Richmond County
beginning January 1,2000 and continuing until December 31,2000.
A. Provision of Services.
University covenants and agrees to provide to the certified indigent residents of
Richmond County all Covered Health Care Services (as defined in Section II.D. below) usually
and customarily provided by it, 'in a prompt and proper manner consistent with professional
standards and all applicable laws and regulations. University further covenants and agrees;o.
provide said services to said patients in the same manner and quality as provided to other patients
of University. It is understood that University customarily provides physician services only in a
limited number of specialties, and only toa limited extent in those specialties. Nothing in this
Agreement is intended to or shall have the effect of expanding University's. obligation to provide
services to certified indigents beyond those Covered Health Services offered by University
Hospital on January 1,2000.
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University reserves the rignt to deny services to any patient who engages in dangerous or
disruptive behavior.
B. Certification of Residency
In order to receive Covered Health Care Services (as hereinafter defined), a patient or
responsible household member must have been a resident of Richmond County for at least six
(6) consecutive months prior to the date Covered Health Care Services are sought. Responsible
household members are persons legally married (whether by ceremony or common-law) or living
in a domestic relationship (as defined in guidelines for purposes of Aid to Families with
Dependent Children eligibility), and the legally responsible parents or guardians of children
under the age of 18. If there is doubt as to. who are the legally responsible parents of children
under the age of 18, a copy of the child's birth certificate shall be required to verify parentage.
Residency must be confirmed by at least one (1) of the following:
a. rent receipts for a period of six (6) consecutive months, a lease, or a
statement by a rental agency or established real estate business that the patient has resided in the
County for at least 6 months;
b. a valid Georgia driver's license showing an examination date at least 6
months old and a Richmond County address;
c. employment c~eck stubs showing the patient's (or a responsible household
member's). address during the preceding 6-month period, or a statement from the patient's (or a
responsible household member's) employer attesting to residence in Richmond County;
d. utility bills or payment stubs (at least one of which is current and at least
one of which is between 6 and -12 months old) in the patient or a responsible household
member's name;
e. a telephone book or city directory listing showing the patient's or
responsible household member's name;
f. a voter registration card issued at least 6 months before and showing a
Riclunond County polling place;
g. attestations of residency (in the form of affidavits) for at 'least 6 months
from the patient and two other people, one of whom must be a minister with a Richmond County
congregation or the director of a private relief organization such as the Salvation Army;
h. a letter from DF ACS verifying receipt of food stamps- from Richmond
County DF ACS; or
1. a currently valid University certification card issued under Section .C.S
below.
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No bill for a patient wliose residency cannot be certified according to the above
requirements shall be submitted to, Qr paid by, the County. University agrees to notify the
County immediately should it receive information that any certification is in error, or that any
patient is attempting to certify residency falsely.
C. Certification ofIndigency
In order to receive Covered Health Care Services (as hereinafter defined) each patient
must be certified as indigent according to this Agreement. As a preliminary matter, such
certification shall confirm that each said patient is with respect to the Covered Health Care
Service "self-pay", that is
a. does not have valid health insurance and/or medical payments coverage
for the Covered Health Care Service (per diem hospitalization reimbursement policies shall not
. be considered health insurance or medical payments coverage, but rather will be included as an
asset for purposes of determining resources, and whenever such assets are involved, each
inpatient hospitalization will require separate certification);
b. does not have Medicare or Medicaid insurance coverage; and
c. does not have workers' compensation coverage for the Covered Health
Care Service.
Unless otherwise disqualified, a patient will be certified as indigent under this Agreement
if the sum ofhislher gross income plus other responsible household members' gross income(s) is
equal to or less than that listed in the attached income scale (based upon the Federal Poverty
Guidelines) for the applicable household size. The attached income scale shall be amended
January 1 of each calendar year iri order to correspond with the then current Federal Poverty
Guidelines. ..
For purposes of this section, responsible household members' gross income includes the
gross income of any dependent children. For purposes of this section, any child (regardless of
age) who is or could be claimed as a dependent on his/her parent's income tax return will be
considered for indigency certification-according to his/her parent's gross income (with respect to
a minor with an absent parent who is not providing support to that minor, the minor shall not be
considered as having income from that absent parent):
1. Determination of Gross Income
For purposes of this section, gross income means any and all income before deductions,
and includes the following:
a. wages. and salaries before any deductions;
b. receipts from self-employment before 'any deductions, or from an
owned farm or business after farm arid business deductions;
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c. public ~ssistance in any form;
d. social security payments;
e. supplemental security income (SSI);
f. unemployment. compensation;
g. workers' compensation payments;
h. veterans's benefits;
1. training stipends;
J. alimony payments;
k. child support payments;
1. military family allotments;
m. regular:support from apsent family members or
persons not living in the household;
government employee pensions;
private pensions;
insurance benefits paid on a regular, annuity-like basis;
annuity payments;
dividends, interests, rents, royalties, Income from estates and
union payments or assistance of any kind; and
t. any other foim of income which results in disposable spending
ability (such as student loans used for living expenses).
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2. Verification of Gross Income
Gross income shall be verified as follows:
a. Possession of a currently valid University certification card issued
under Section C.S below; or
b. For food stamp recipients, gross income shall be determined from
DFACS records (unless such records are more than 12 months old); or
c. For other than food stamp recipients (or for those whose DFACS
records are more than 12 months old), gross income shall be determined from federal and/or state
income tax returns for the immediately preceding year for the patient and all responsible
household members and with all children (except those born after the end of the last tax year)
accounted for as dependents, with adjustments made to bring figures current; or
d. Where income tax returns are not, available, the patient and all
responsible household members shall be required to disclose under oath all income (as defined in
this Section II.C.) received in the last 8 weeks from all sources. Income shall be verified
according to DF ACS routine standards.
University shall require patients to authorize DF ACS to access their income records from
the computer records of the Oeorgia Department of Labor. Any patient refusing to provide such
authorization shall not be certified as indigent. Within seven days of its receipt of the
authorization, DF ACS will notify University if the DOL income exceeds the patient's certified
indigency level.
3. Resources
Once a patient's income is determined, DF ACS shall determine the resources of that
patient. Any patient whose total resources exceed $1,500.00 shall not be certified as indigent;
provided, however, that in the event said patient's resources later fall below $1,500.00, said
'patient may reapply for indigent certification, and said patient will be allowed to pay toward
his/her billings from University for Covered Health Care Services until the $1,500.00 figure is
reached. For purposes of this section, "resources" include the following:
a.
manufactured homes);
real estate equity value (real estate. includes mobile or
b.
counted as resources);
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cash reserves (except that cash reserves of $800.00 or less are not
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c. equity value of automobiles and other vehicles (except that up to
two vehicles used by the patiynt and/or household members for transportation to and from work
or used regularly for seeking work will not be counted as resources); and
d. life insurance (except that the first $3,000.00 of cash value for life
insurance for the patient and each responsible household member shall not be counted as
resources).
e. per diem hospitalization policy payments (each inpatient admission
involving a person with this resource must be separately certified).
A transfer of resources solely for the purpose of becoming or remaining eligible
for indigent status under this Agreement may result in disqualification of the applicant.
Determinations of whether a transfer of resources as contemplated herein has occurred, and
whether disq'ualification is warranted shall be made by DF ACS, in its sole discretion, applying
current AFDC, or other appropriate guidelines.
4. Other Requirements and Standards for Patients
a. Medicaid/SSI
Unless excused in writing by DF ACS, within 60 days of the issuance of a certification
card as a Richmond County indigent, a patient must make a formal application through DF ACS
for Medicaid coverage. If a patient refuses to make such application, or if Medicaid coverage is
denied due to an excess in resources, the patient's indigent certification will be retroactively
revoked.
, If determined by DF ACS to be SSI eligible, within 30 days of notification from DF ACS a
patient must make a formal application through DF ACS for SSI coverage. , If a patient refuses to
make such application, or if SSI coverage is denied due to an excess in resources, the patient's
indigent certification will be revoked retroactive to the date of notification to apply for SSI.
In the event an application fC!r- either Medicaid or SSI coverage is denied due to
procedural grounds (including, but nor limited to the patient's failure to cooperate in the
application process), the patient's indigent certification will be retroactively revoked.
b. Unemployment
Any patient or responsible household member claiming to be unemployed must produce
evidence of disability or verification from the Georgia Department of Labor that he/she has
registered with them and has received -an Employment Application Card and is active in the
"Peach Program"; provided, however, that this subsection does not apply to adults legally
responsible for the care of young children (under age 12) or a disabled individual.
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c. Food Stamps
If determined by DF ACS to be eligible for food stamps, within 30 days of notification
from DF ACS, a patient must make a formal application through DF ACS for food stamps. If a
patient refuses to make such application, or if food stamp eligibility is denied due to an excess in
resources (except a vehicle exempt under II. C. 3.c. above), the patient's indigent certification
will be revoked. Further, if an application for food stamps is denied due to procedural grounds
(including, but not limited to the patient's failure to cooperate in the application process), the
patient's indigent certification will be revoked retroactive to the date of notification to apply for
food stamps.
d. Records
Unless a longer period is specified, patients must provide any information requested in
connection with the certification and billing process within fifteen (15) business days of request.
Failure to do so shall result in a denial of indigent certification or revocation retroactive to the
date of the request.
5. Certification Process
All certification cards areto be provided by University and issued by DFACS. Cards are
valid for any Covered Health Care Service event ending 60 days immediately preceding issuance
and for the 12 month period after issuance; provided, however, that nothing herein shall obligate
either University or County to provide indigent care to such individuals beyond the term of this
Agreement.
DF ACS shall make all efforts to process certifications within 30 days from its receipt of a
request for certification. DFACS shall station at least one employee to accept Medicaid
applications at University's outpatient clinics during clinic hours. This processing time shall be
tolled during any period within which the DF ACS. worker is waiting for information from the
patient; provided, however, that if such information is not forthcoming in the time period
specified in Section II. CA. above, certification shall be denied. In the event DF ACS does not
process certifications in the time specified above, the patient shall be provisionally certified as
100% indigent. In the event the'pati,ent is later determined by either DF ACS or the County to be
less than 100% indigent, the provisional certification shall be revoked and the County shall
receive a credit in accordance with Section Il.H.3. below.
The application for indigency shall not require more than a sixth grade education to
complete, and shall not be longer than -1 page in length.
DF ACS shall keep University apprised of the name, address and telephone number
provided by each patient seeking certification as indigent. University reserves the right to assist
DF ACS in the certification process when deemed necessary. DF ACS shall notify University
when an applicant has only 3 business days. remaining before possible denial of certification
based on Section H.C. 4 above. .
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University agrees to inform DF ACS . whenever it learns of a change in status of a patient,
or otherwise obtains information suggesting that the certification level of a patient should be
changed.
Where certification is denied based upon an applicant's failure to provide documentation
or verification of information, or an applicant's income and/or resources, that applicant may
reapply for certification beginning on the 31st day following denial. Where certification is
denied based upon an applicant's residency status, the applicant may reapply for certification in
the month in which the residency req).1irement is met. Documentation required for reapplication,
including a new application where applicable, will be as is determined by DF ACS.
6. Reports
University agrees, using information provided to it by DF ACS, to produce reports in
substantially the form attached hereto as Exhibit "A" and to provide such reports to the County
as they are created. University further agrees to create and provide to the County such other
reports as the County may reasonably request from time to time in order to evaluate the
performance of University under this Agreement.
7. Appeals Process
Patients denied indigent certification, denied a higher certification level, or whose
indigent certification is revoked, may appeal such determinations to the Director of DF ACS.
Such appeal must be in writing and submitted to said Director no more than 30 days after the
date of denial or revocation. The Director shall make his determination on the issue and submit
it to the Appeals Board for final 'approval or disapproval. If the denial, lower certification level,
or revocation is overturned, all' Covered Health Care Services from 60 days prior to the
submission of the original request for certification shall be covered under the indigent
certification determined by the Appeals Board.
D. Covered Health Care Services
With the exceptions set out in this Section, Covered Health Care Services includes only
those inpatient services, outpatient observation admission, outpatient surgical services and
emergency room services generally provided at University Hospital. Only those Covered Health
. Care Services which are medically necessary are to be provided to certified indigent residents of
Richmond County pursuant to this Agreement. The following health care services are not
covered and shall not be paid for by the County:
1. Inpatient and outpatient services and/or procedures not covered by the
Georgia Medicaid program or the federal Medicare program.
2. Services provided on an inpatient basis which are routinely provided on an
outpatient basis; provided, however, that inpatient diagnostic procedures will be covered when
performed in conjunction with treatment requiring an inpatient admission or an outpatient
observation admission.
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3. Cosmetic surgery; provided, however, that reconstructive surgery IS a
covered service.
4. Physician fees; provided, however, that the fees of physicians who are
salaried by or under contract with University are covered when incurred in conjunction with a
Covered Health Care Service.
5. Ambulance. and other transport services.
6. Abortions; provided, however, that an abortion performed when the
mother's life is in danger is covered.
7. Home Health Care Services; provided, however, that when a physician
states in writing that the providing of Home Health Care Services are necessary to avoid an
inpatient admission or to avoid extending an inpatient admission, those services will be covered.
8.
for certification.
Any service rendered more than 6 months prior to a patient's initial request
E.
Non-Covered Patients
The individuals listed below are not eligible for indigent care payments by the County:
1. Any person receiving Cancer State Aid except when program
funds. are exhausted as to that person or the Covered Health Care Service is not covered by
Cancer State Aid.
2. Any veteran eligible for Veterans' Administration assistance for
the Covered Health Care Service; provided, however, that DF ACS must establish non-eligibility
with some evidence beyond veteran status and a disability pension of 50% or less.
3. Any member of the military or -any military member's
dependent(s).
4. Any person- not a resident of Richmond County; provided,
however, that the coverage of a person while a resident who later moves away, is not affected by
this provision.
5. Any person who, within the last 3 years, was convicted of welfare
fraud, entered into a disqualification consent agreement, was determined at an administrative
hearing to have committed an intentional welfare program violation, or who waived a
disqualification hearing with respect to a, charge of welfare fraud or intentional program
violation.
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6. Any college student who is c~vered under his/her parent's
insurance coverage, or who is provided health care services oy the college or institution in which
he/she is enrolled;
7. Any . transient worker, such as a construction or agricultural
worker, who is domiciled outside of Richmond County.
8. Any resident of a public institution.
9. Any individual domiciled outside. Richmond County who is
present in Richmond County due to participation in a h~lfway house program or other
rehabilitation program.
10. Any illegal alien or illegal immigrant.
11. Any patient who initiates a lawsuit to. establish SSI disability;
provided, however, that the initiation of such a lawsuit only suspends coverage as an indigent
until resolution of the lawsuit, at which time those services not otherwise paid for by Medicare or
Medicaid may be paid for by the County. .
12: Any and all inmates whose health costs are covered by the local,
state or federal penal institution in which he/she is being housed.
F. Payments by Patient
Each certified indigent resident of Richmond County will be required to make payments
toward his/her bill in accordance with the provisions of the September 20, 1977 Agreement
between University and the Countyconceming indig~nt care; however, a failure to make
payments will not automatically disqualify the resident. University may charge any certified
Richmorid indigent patient seen at an Indigent Care Trust Fund primary care off-campus
expansion clinic in accordance with the sliding schedule set forth in the September 20, 1977
Agreement. University may, in its discretion, revoke a certification card after giving the holder
thirty (30) days' advance written notice that the card will be revoked for failure to make payment
in accordance with the cardholder's status. The revocation will have prospective effect only.
The individual whose card is revoked inthis manner may not subsequently be issued an indigent
certification card without the written ,approval of University.
G. Payments by County
County shall not be responsible for the payment of any costs and/or charges for any
person. not certified as. an indigent resident of Richmond County in accordance with this
Agreement.
. For all "certified", indigent residents of Richmond County, County shall be responsible
for payment within thirty days of receipt of a bill for Covered Health Care Services provided by
University pursuant to this Agreement as follows:
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1. Emergency Room
For all certified indigent residents, County agrees to pay the "cost" for all Covered Health
Care Services provided in University's Emergency Room, including services provided by
physicians either salaried by or',under contract with University, less, where applicable, the
amount of patient payment required by the patient's certification level whether or not the patient
makes the payment. 'As to Covered Health Care Services, "cost" means the product of charges
for such services multiplied by University's most recent Medicare cost-to-charge ratio. As to
physicians' services, "cost" means the physicians' fees as determined by CPT -4 billing codes and
Medicaid fee schedule.
2. Outpatient Services, Surgery and Outpatient Observation
Admissions
For all certified indigent residents, County agrees to pay the "cost" for all Outpatient
Surgery and Outpatient Observation Admissions at University Hospital, which are Covered
Health Services, inc1udingservices provided by physicians either salaried by or under contract
with University, less, where applicable, the amount of patient payment required by the patient's
certification level whether or not the patient makes the payment. As to Covered Health Care
Services, "cost" means the product of charges for such services multiplied by, University's most
recent Medicare cost-to-charge ratio. . As to physicians' services, "cost" -means the physicians'
fees as determined by CPT -4 billing codes and Medicaid fee schedule.
3. Inpatient
For all certified indigent residents, County agrees to pay the "cost" for all Covered Health
Care Services provided on an inpatient basis, including services provided by physicians either
salaried by or under contract with University, less, where applicable, the amount of patient
payment required by the patient's certification level whether or not the patient makes the
payment. As to Covered Health Care Services, "cost" means the product of charges for such
services multiplied by University's most recent Medicare cost-to-charge ratio. As to physicians'
services, "cost" means the physicians' fees as determined by CPT -4 billing codes and Medicaid
fee schedule.
4. Cap on Payments
R.egardless of actual costs and/or charges incurred and billed under this Section II.,
County shall not payor be required to pay in excess of One Million Two Hundred Fifty
Thousand Dollars' ($1,250,000.00) (hereinafter referred to as the "Cap") for Covered Health
Care Services rendered pursuant to this Agreement. It is agreed that the level of care provided
under this Agreement shall not be less than the level of care provided to certified indigents under
the Agreement dated January 1, 1999 eventho,ugh funding hasbeen reduced to $1,250,000.00.
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H. Credits to County
University agrees to continue its collection efforts on all unpaid bills for which the
County is entitled to a credit under this Agreement. County is entitled to a credit, to the extent of
its payment on a particular patient account, on its next billing, as follows:
1. to the extent of University's recovery under any lien imposed under
Georgia law;
2. to the extent any indigent certification is revoked for any reason, or
is denied after Covered Health Care. Services are provided (nothing iri this Agreement shall
restrict University's right to seek payment from any such individual); and
3. to the extent University collects more from a certified patient than
that patient's liability under the patient's certification level.
I. Billings to County
1. University's billings to the County shall contain the following
information:
a. Name of patient; address of each patient; date of
each service; CPT code for each outpatient service or the ICD-9
code for inpatient service; the charge for each service; and, the
County liability for each service
b. A summary by area (emergency room, inpatient,
outpatient, and outpatient observation) which includes total
charges, total County liability, applicable cost to charge ratio,
credits by type, and errors or omissions discovered during the
billing period related to prior bills
A list of the current certified indigent care card
d. A statement signed b~ University's CFO and
President that the billings comply with this Agreement and that
billings inClude only individuals certified by DF ACS
2. University shall provide County the following:
a. University's most recent Medicare Cost Report and
all subsequent changes thereto
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. b.- Upon request, University will provide access to its
charge master as of January 1; 2000 and all subsequent changes
thereto. 1;'he County shall hold the charge master in strict
confidence and will not redisc10se charge master information
3. University shall provide County within a reasonable time after a
request for a. specific account information, the payment detail of any
account upon which County makes a payment.
J. Review of 2000 Billings'
The parties agree that County (or its designated agent) shall be allowed to review all
billings by University to the County and that University shall furnish to County (or its designated
agent) all documents and materials necessary for County to complete said review. Unless
County requests in writing additional specific documents, County shall be deemed to have
received all necessary documents and materials thirty days after receipt of each bill. County
shall have 90 days from the later of the receipt of each bill or its receipt of spe~ifically requested
additional billings, documents and materials to complete its review. After said 90 day period, the
bills shall be final and uncontestable, except as limited by the Cap. The payment of bills shall
not be delayed by review under this section.
SECTION III. AMBULANCE SERVICES
No charges shall be made by University to the County under this Agreement with regard
to ambulance service provided by University to certified indigent residents of Richmond County.
All aspects of such ambulance services shall be covered by and under the Agreement for
ambulance services dated September 23, 1971 as amended, and ,!S modified by University's
"Management Services Agreement" with EMS Ventures d/b/a Rural/Metro Corporation dated
June 21, 1996.
SECTION IV. MISCELLANEOUS PROVISIONS
A. Amendment
This Agreement may be ameridedonly by the express written consent and agreement of
both parties hereto.
B. Sole Agreement
This Agreement represents the entire agreement between the parties hereto and
supersedes any and all previous written andjororal agreements or understandings.
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C. Future Contracts
The parties agree that the funding obligations and the descriptions of Covered Health
Care Services set forth in this Agreement apply during tlie term of this Agreement, to-wit:
calendar year 2000, only, and that nothing herein shall obligate the County to continue to provide
to University the same level of funding for the same services as are set forth herein.
D. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of the
State of Georgia.
E. Severability
In the event any provision of this Agreement is rendered invalid or unenforceable under
any law. or regulation, or declared null and void by any court of competent jurisdiction, the
remainder of the provisions of this, Agreement shall, subject to this paragraph, remain in full
force and effect.
F. Waiver
Waiver of a breach of any provision of this Agreement shall not be deemed a waiver of
any other breach of the same or different provisions.
G. Notices
Any notice to be given hereunder by one party to the other shall be effected in writing
and may be delivered either by certified U.S. mail with return receipt requested, by regular U.S.
mail, properly addressed and postage prepaid, by overnight mail or by hand-delivery to the
addresses listed below. Any party may change its address below by written notice given in
accordance with this Section. Notices delivered personally shall be deemed received upon actual
receipt. Notices mailed shall be deemed received no later than two (2) United States Postal
Service business days after the date of such mailing.
To University:
University Health Services, Inc.
Robert M. Taylor, Chier'Financia1 Officer
1350 Walton Way
Augusta, Georgia 30901-2629
To County: .
Augusta-Richmond County Commission
c/o Charles R. Oliver, Administrator
8th Floor - City-County Building (11)
530 Greene Street
Augusta, Georgia 30911
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IN WITNESS WHEREOF, the parties hereto have set their hands and seals as of the day
first above written.
AUGUSTA, GEORGIA by and through the
Augusta- ond County Commission
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UNIVERSITY HEALTH SERVICES, INC.
By:
Name:
Title:
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Richard H. ParKs
President/CEO
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