Osah Form 1 (Department Of Public Health)

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OSAH FORM 1
AGENCY
CASE TYPE
DOCKET NUMBER
COUNTY
JUDGE
OSAH USE
DPH
ONLY:
DEPARTMENT OF PUBLIC HEALTH
Non-Agency Party’s County of Residence: Date Hearing Request Filed with Agency:
Agency Reference Number:
Check here if an APPLICATION was denied:
Check Only One:
EMS (Emergency Medical Services)
BCW (Babies Can't Wait)
(includes air and ground ambulance, medical first
responder, and neonatal transport services)
FSEP (Food Service Establishment Permit)
EMSP (Emergency Medical Service Personnel)
LR (Local Registrar)
(includes cardiac technicians, paramedics, all
categories of emergency medical technicians, and
SSM (Sewage Management)
instructors)
WICV (WIC Vendor)
NON-AGENCY PARTY
NAME:
TEL #:
FAX #:
CURRENT ADDRESS INCLUDING ZIP CODE:
EMAIL:
ATTORNEY FOR NON-AGENCY PARTY (IF APPLICABLE)
NAME:
TEL #:
FAX #:
ADDRESS INCLUDING ZIP CODE:
GEORGIA BAR #:
EMAIL:
CONTACT PERSON AT REFERRING AGENCY
NAME:
TEL #:
FAX #:
ADDRESS INCLUDING ZIP CODE:
POSITION:
EMAIL:
ATTORNEY FOR REFERRING AGENCY
NAME:
TEL #:
FAX #:
ADDRESS INCLUDING ZIP CODE:
GEORGIA BAR #:
EMAIL:
***DOCUMENT(S) INITIATING THE REFERRAL MUST BE ATTACHED***
This form is available online at
or by telephone request at (404) 657-2800.

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