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PRINTED: 06/15/2016 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER: COUNTRY CHARM VILLAGE (X4) ID
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Obtain the identification number form from the relevant authority or organization. This could be a government agency, financial institution, or any institution that requires individuals to have an identification number.
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Fill in your personal information accurately and legibly. This typically includes your full name, date of birth, address, and contact information. Make sure to double-check the information before proceeding.
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Provide any supporting documents required. This may include copies of your identification card, passport, or any other relevant identification documents requested by the authority or organization.
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Identification number - in is a unique code or number assigned to individuals or entities to identify them for tax or other purposes.
Entities or individuals who are required to do so by law or regulations.
The identification number - in can be filled out on official forms provided by the relevant authority, usually requiring personal or entity information to be input.
The purpose of the identification number - in is to uniquely identify individuals or entities for tax or other legal purposes.
The information required to be reported on the identification number - in typically includes personal or entity details such as name, address, and other identifying information.
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2016 Indiana IN00200418 X5 payor IAC X6 DTXR11 QR HWY LSC X2 CLIA X1 X3 X4 REFERENCED INDIANAPOLIS DEFICIENCIES REGULATORY Unsubstantiated PREFIX continuation CORRECTIVE PRECEDED Medicare Medicaid compliance DEFICIENCY Census PROVIDER SUMMARY

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