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PRINTED: 04/02/2012 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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First, gather all the necessary information, such as the date, department name, and relevant details.

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Write the date in the designated space, ensuring it is accurate and formatted correctly (MM/DD/YYYY).

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