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PRINTED: 04/27/2016 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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01
To fill out Burnsides Community Health Center form, follow these steps:
02
Obtain the form: You can either visit the center and request a copy of the form or download it from their official website.
03
Read the instructions: Carefully read the instructions provided with the form. Make sure you understand the requirements and any specific guidelines.
04
Provide personal information: Fill in your personal details such as name, address, phone number, and date of birth. Ensure the information is accurate and up to date.
05
Medical history: Provide details about your medical history, including any pre-existing conditions, allergies, surgeries, medications, etc.
06
Insurance information: If applicable, provide your insurance details, including the insurance company name, policy number, and group number.
07
Sign and date the form: Once you have completed filling out the form, sign and date it to certify the provided information.
08
Submit the form: Return the completed form to Burnsides Community Health Center through the designated submission method mentioned in the instructions. You may need to visit the center in person or send it by mail.
09
Follow up: If required, keep track of any additional steps or appointments mentioned in the instructions after submitting the form.

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Burnsides Community Health Center is beneficial for individuals who require access to affordable healthcare services, including:
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- Uninsured individuals: The center provides healthcare services to those without insurance.
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- Low-income individuals: Burnsides Community Health Center offers discounted or free care to individuals with low income.
04
- Medically underserved individuals: If you live in an area with limited access to healthcare services, Burnsides Community Health Center can be a crucial resource.
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- Vulnerable populations: The center aims to serve vulnerable populations like children, seniors, pregnant women, individuals with disabilities, and those facing challenges in accessing healthcare.
06
- Individuals seeking comprehensive care: If you are in need of primary care, dental care, behavioral health services, or other healthcare services, Burnsides Community Health Center can cater to these needs.
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Burnsides Community Health Center is a non-profit organization that provides healthcare services to the community.
All healthcare providers and organizations who are affiliated with the center are required to file Burnsides Community Health Center forms.
To fill out Burnsides Community Health Center forms, you will need to provide detailed information about the healthcare services provided, patient demographics, and financial data.
The purpose of Burnsides Community Health Center is to improve the overall health and well-being of the community by providing accessible healthcare services.
Information such as patient demographics, services provided, financial data, and any community outreach programs must be reported on Burnsides Community Health Center forms.
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