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/document/document/1095-b-notification-letter/download&sa=U&ved=2ahUKEwiPjsf-zpaHAxVlhv0HHZJ6AeM4MhAWegQIBxAB&usg=AOvVaw1JG_reh47wqcL_84y2mxJN&fexp=72519171,72519168