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1.00PRINTED: 1/31/2017DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)FORM APPROVED2567L(XI) PROVIDER/SUPPLIER/CIA
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What is name of provider or?
Name of provider refers to the entity or individual that is supplying a service or product.
Who is required to file name of provider or?
The individual or entity providing the service or product is required to file the name of provider.
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You can fill out the name of provider by providing the legal name or business name of the entity or individual.
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The purpose of name of provider is to accurately identify the source of the service or product being provided.
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The information reported on name of provider must include the legal or business name of the provider.
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