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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15532905/10/2012FORM

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3. Ensure that you have all the relevant details about the incident or topic being investigated.
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5. Double-check your entries for any errors or omissions before submitting the form.
6. If you are unsure about any section or question, seek clarification from the appropriate authority or supervisor.
7. Sign and date the completed form to validate it.
8. Submit the form to the designated person or department, following the specified submission process.
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