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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 155775

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Printed-in refers to a physical form that needs to be filled out and filed with relevant parties.

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The specific information required on printed-in forms can vary, but typically includes personal or business details, signatures, and relevant data.