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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: 15G403

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3. Use a pen or pencil: Select a pen or pencil to fill out the form. It is important to use a writing instrument that is suitable for the type of paper or surface of the form. A pen with blue or black ink is most commonly used, but in some cases, a specific color or type of pen may be required, so refer to the instructions.
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7. Verify the form's requirements: Confirm that you have filled out all the required fields on the printed-in form. Look for any mandatory sections or information that needs to be provided. If you encounter any optional sections, evaluate if it is necessary or recommended to fill them out.

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