Would the hospital like to participate in the FFY 2023 DSH program?
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Must select Yes or No.
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Would the hospital like to participate in the DY12 UC program?
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Must select Yes or No.
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Note: The Primary Application Contact and Primary Hospital Contact MUST be a different individual.
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The Primary Application Contact, this person is authorized to act as a liaison between the hospital and HHSC.
(This person can be a contractor.)
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Primary Application Contact Name
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Primary Application Contact Telephone
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Primary Application Contact Email
example: first.last@hosp.com
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Please enter a valid email address.
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Note: The Secondary Application Contact and Primary Hospital Contact MUST be a different individual.
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Secondary Application Contact, the person designated to complete the DSH/UC Application on behalf of the Primary Hospital Contact.
(This person can be a contractor.)
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Secondary Application Contact Name
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Secondary Application Contact Telephone
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Secondary Application Contact Email
example: first.last@hosp.com
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Please enter a valid email address.
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