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FOR BHF USELL1
2011
STATE OF ILLINOIS
DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
FINANCIAL AND STATISTICAL REPORT (COST REPORT)
FOR LONGER CARE FACILITIES
(FISCAL YEAR 2011)I.DPH License ID Number:
Facility
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Information such as patient demographics, medical history, current health status, and rehabilitation progress must be reported on the form.
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