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PRINTED: 07/29/2015 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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Start by gathering all the necessary information about the eligible hospital.
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Fill out the personal details section, including the hospital's name, address, and contact information.
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Provide information about the hospital's eligibility, such as its certification status and any relevant accreditation.
04
Include details about the hospital's services and specialties, including any specific programs or departments.
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Fill out the financial information, including the hospital's annual budget, revenue sources, and any grants or funding received.
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Who needs information for eligible hospitals?

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Anyone involved in the process of assessing or evaluating eligible hospitals, such as government agencies, regulatory bodies, or insurance providers.
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Hospital administrators or management personnel who need to provide comprehensive information about their hospital.
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Researchers or analysts studying healthcare systems or hospital performance.
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Information for eligible hospitals includes data and documentation required to demonstrate compliance with specific regulations or requirements.
Eligible hospitals are required to file information for compliance purposes.
Information for eligible hospitals can be filled out online using the designated platform or submitted via mail.
The purpose of information for eligible hospitals is to ensure that hospitals are meeting regulations and requirements for eligibility.
Information such as patient statistics, financial data, and quality metrics must be reported on information for eligible hospitals.
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