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PRINTED: 04/16/2015 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:CENTRAL INDIANA AMG SPECIALTY

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1. Begin by gathering all the necessary personal and demographic information such as name, address, date of birth, and social security number.
2. Visit the official website of the Indiana State Department of [enter department name] and navigate to the appropriate form.
3. Carefully read the instructions provided on the form to ensure you understand the requirements and provide accurate information.
4. Fill out the form electronically or print it out and complete it by hand, as per the specified instructions.
5. Double-check all the entered information for accuracy and completeness.
6. If there are any sections or fields that you are unsure about, contact the Indiana State Department of [enter department name] for clarification.
7. Sign and date the completed form as required.
8. Make a copy of the filled-out form for your records.
9. Submit the completed form to the Indiana State Department of [enter department name] by mail, in person, or through the online submission portal, depending on the specified instructions.
10. Follow up with the department if necessary to ensure that your form has been received and processed.

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1. Any individual residing in the state of Indiana who is required to provide specific information or documentation to the Indiana State Department of [enter department name] needs to fill out the applicable forms.
2. Examples of people who may need to fill out forms with the Indiana State Department of [enter department name] include residents applying for various licenses, permits, benefits, or services offered by the department.

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