MODIFICATIONS TO THIS AGREEMENT CANNOT AND WILL NOT BE AGREED TO. THIS AGREEMENT IS NOT TRANSFERABLE OR ASSIGNABLE. Name Provider Agency Head Title Agency Head – – Provider Agency Head Date Signed SIGNATURE – Name Administrator or Designee Division of Long Term Care – SIGNATURE Administrator or Designee Division of Long Term Care Date Signed – Name Agreement Administrator – Agreement Administrator Date Signed SIGNATURE –
MODIFICATIONS TO THIS AGREEMENT CANNOT AND WILL NOT BE AGREED TO. THIS AGREEMENT IS NOT TRANSFERABLE OR ASSIGNABLE. Name – Provider Agency Head Title – Agency Head SIGNATURE – Provider Agency Head Date Signed Name – Administrator or Designee Division of Long Term Care SIGNATURE – Administrator or Designee Division of Long Term Care Date Signed Name – Agreement Administrator SIGNATURE – Agreement Administrator Date Signed
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