This government document is issued by Department of Community Health for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://dch.georgia.gov/sites/dch.georgia.gov/files/related_files/site_page/Interim_Provider_Payment_Request_Form.pdf&sa=U&ved=2ahUKEwiZ_4On05aHAxWuUkEAHSZRDpk4UBAWegQICBAB&usg=AOvVaw2WwUP581q6iUZ0zZ0gZgsT&fexp=72519171,72519168