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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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.
<<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>>