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02/28/2018PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION

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Step 1: Start by gathering all the necessary information and documents required to fill out the form.

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Step 2: Begin by writing your full name and contact information on the designated spaces provided.

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