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PRINTED: 07/23/2012 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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Start by writing the date in the designated space. The format is MM/DD/YYYY, so for July 23, 2012, you would write 07/23/2012.
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Next, enter your department code in the specified area. Make sure to double-check the code to ensure accuracy.
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Provide your full name in the appropriate section. Include your first name, middle initial (if applicable), and last name.
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Write your job title or position in the provided space. Be specific and use the official title assigned to you.
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Enter your employee ID number. This unique identifier helps the department keep track of its employees.
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Specify your work shift, whether it is day, evening, or night. If you have a fixed schedule, indicate the exact hours you work.
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Printed 0723 department is a document used by the Department of Revenue to report certain tax information.
Individuals or businesses who meet specific criteria set by the Department of Revenue are required to file printed 0723 department.
Printed 0723 department can be filled out manually or electronically, following the instructions provided by the Department of Revenue.
The purpose of printed 0723 department is to report tax information to the Department of Revenue for processing and compliance purposes.
Printed 0723 department requires the reporting of specific tax-related information, such as income, deductions, and credits.
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