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["Listing of Non-Covered Medicaid Eligible Days - SFY/FFY 2017"]
["Hospital Name:   ___________________________________________"]
["Provider #:  _____________"]
["FYE:  _____________"]
[]
[null,null,null,"Dates of Service Not Paid/","# of Days Not Paid/"]
["Medicaid Recipient ID#","Social Security #","Patient Name","Covered By Medicaid","Covered by Medicaid"]
{"$rows_empty":33}
[null,null,null,"Total Days:"]
["Note:  Do not include nursery days that were covered on the mother's bill or any other days that were included in Medicaid days on  the  cost report."]