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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202 DIVISION OF MEDICAID & CHILDREN HEALTH REGION
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January 5, 2016 refers to the date a specific form was filed.
Certain individuals or entities may be required to file the form on January 5, 2016.
The form can be filled out online or submitted through mail with specific instructions provided.
The form serves the purpose of reporting certain information to the relevant authority.
Specific information relevant to the form must be accurately reported.
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