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PRINTED: 06/25/2014 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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Information such as the identity of the parties involved, the nature of the transaction, and the source of funds must be reported on 25d no caformter prevent.