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PRINTED: 01/26/2016 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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Step 1: Begin by gathering all necessary personal information such as your full name, date of birth, social security number, and contact information.
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Step 2: Fill in the top section of the form with your personal information.
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Step 3: Provide your current address and any previous addresses for the past two years.
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Step 4: Indicate your insurance information, including the name of your insurance provider, policy number, and group number if applicable.
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Step 5: If you have any specific medical conditions or allergies, make sure to include them in the appropriate section.
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Step 6: Complete the emergency contact section by providing the name, relationship, and contact information of someone to reach in case of an emergency.
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Step 8: Review the completed form for any errors or omissions before submitting it to Prairie Village Healthcare Center.

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Anyone in need of healthcare services can benefit from Prairie Village Healthcare Center.
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Prairie Village Healthcare Center is a nursing home facility that provides skilled nursing care for residents.
The management or owners of the Prairie Village Healthcare Center are required to file the necessary paperwork.
To fill out Prairie Village Healthcare Center paperwork, one must provide accurate and detailed information about the facility's operations and services.
The purpose of Prairie Village Healthcare Center is to ensure high-quality care and compliance with regulatory guidelines.
Information such as patient demographics, staffing levels, quality measures, and financial data must be reported on Prairie Village Healthcare Center forms.
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