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PRINTED: 08/30/2010 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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1. Start by writing your full name in the designated space at the top of the form.
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3. If applicable, include any apartment or unit numbers after the street address.
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5. Fill in any additional information required, such as your date of birth or social security number, if necessary.
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7. Review the completed form for accuracy and ensure that all fields are properly filled out.

Who needs 10124 South Kedzie:

1. Individuals who reside or own property at 10124 South Kedzie would need this address for various purposes.
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10124 south kedzie is an address located at South Kedzie Avenue.

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