
Get the free PRINTED: 1212312011 FORM APPROVED OMB NO. 0938 0391 - chfs ky
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PRINTED: 05/25/2012 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION
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The printed 1212312011 form is a tax form used for reporting certain information to the IRS.
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