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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES01/09/2012FORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 09380391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION

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Survey dates december 19 refer to the specific dates designated for conducting a survey in December.

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Individuals or organizations who are selected or mandated to participate in the survey on December 19 are required to file.

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