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PRINTED: 04/03/2013 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION

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The purpose of printed department form 0403 is to report specific information to the relevant department.

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Information such as income, expenses, and other relevant financial data may need to be reported on printed department form 0403.

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