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OSAH FORM 1 This form is available online at http //www. osah. ga.gov or by telephone request at 404 657-2800. OSAH USE ONLY AGENCY CODE DOCKET NUMBER DCH DIVISION CODE CASE TYPE COUNTY JUDGE HFR GEORGIA DEPARTMENT OF COMMUNITY HEALTH HEALTHCARE FACILITY REGULATION DIVISION CASES Date Request for Hearing Filed with Agency Non-Agency Party County of Residence Agency Case Number Check Here an if Application Was Denied Check Only One in This Box AST.

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