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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15519712/18/2012FORM
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To fill out form 1113-111612, follow these steps:
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Step 1: Enter the required general information such as your name, address, contact details, and social security number.
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Step 2: Provide details about the facility for which you are applying, including the facility name, address, and type of services provided.
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To fill out form 1119-112012, follow the same steps mentioned above but provide the specific details for that particular facility.

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The 1113-111612 and 1119-112012 facility refers to specific forms for reporting certain types of information to authorities.
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