Sample "Letter of Delegation for Use With Attestation/Certification of Reports, Data, Mpi Plans, Etc. - Florida Agency for Health Care Administration"

Download Sample "Letter of Delegation for Use With Attestation/Certification of Reports, Data, Mpi Plans, Etc. - Florida Agency for Health Care Administration"

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Sample "Letter of Delegation for Use With Attestation/Certification of Reports, Data, Mpi Plans, Etc. - Florida Agency for Health Care Administration"

1

SAMPLE LETTER OF DELEGATION

FOR USE WITH ATTESTATION/CERTIFICATION OF REPORTS, DATA, MPI

PLANS, ETC.

<<DATE>>

Agency for Health Care Administration

<<Applicable AHCA Contract Contact Name>>

<<Name of Applicable Agency Bureau>>

2727 Mahan Drive, MS # <<Applicable Bureau Mail Stop Address #>>

Tallahassee, Florida 32308

Re: Delegation of authority

Dear <<Applicable AHCA Contract Contact Name>>:

I, <<Staff Name>>, << Title>> of <<HEALTH PLAN NAME>>, pursuant to 42 CFR

438.606, hereby delegate authority to <<Designee Name>>, << Designee Title>>, who reports

directly to the <<HEALTH PLAN NAME>> Chief Executive Officer or <<HEALTH PLAN

NAME>> Chief Financial Officer, to execute and attest to the accuracy, completeness and

truthfulness of <<TITLE/TYPE OF DOCUMENT(S)/DATA>> submitted to the Agency for

Health Care Administration (“Agency”) on behalf of <<HEALTH PLAN NAME>>.

<<Designee Name>>shall hereby have representative capacity and express authority to execute

and attest to the aforementioned documents until such time as the Agency is notified by

<<HEALTH PLAN NAME>>, or the term of the subject contract between the parties is

terminated or expires, whichever is sooner.

Sincerely,

<<S

TAFF NAME,

<<TITLE>> (Must be CEO or CFO)

<<HEALTH PLAN NAME>>

SAMPLE LETTER OF DELEGATION

FOR USE WITH ATTESTATION/CERTIFICATION OF REPORTS, DATA, MPI

PLANS, ETC.

<<DATE>>

Agency for Health Care Administration

<<Applicable AHCA Contract Contact Name>>

<<Name of Applicable Agency Bureau>>

2727 Mahan Drive, MS # <<Applicable Bureau Mail Stop Address #>>

Tallahassee, Florida 32308

Re: Delegation of authority

Dear <<Applicable AHCA Contract Contact Name>>:

I, <<Staff Name>>, << Title>> of <<HEALTH PLAN NAME>>, pursuant to 42 CFR

438.606, hereby delegate authority to <<Designee Name>>, << Designee Title>>, who reports

directly to the <<HEALTH PLAN NAME>> Chief Executive Officer or <<HEALTH PLAN

NAME>> Chief Financial Officer, to execute and attest to the accuracy, completeness and

truthfulness of <<TITLE/TYPE OF DOCUMENT(S)/DATA>> submitted to the Agency for

Health Care Administration (“Agency”) on behalf of <<HEALTH PLAN NAME>>.

<<Designee Name>>shall hereby have representative capacity and express authority to execute

and attest to the aforementioned documents until such time as the Agency is notified by

<<HEALTH PLAN NAME>>, or the term of the subject contract between the parties is

terminated or expires, whichever is sooner.

Sincerely,

<<S

TAFF NAME,

<<TITLE>> (Must be CEO or CFO)

<<HEALTH PLAN NAME>>

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