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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15513307/22/2015FORM

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To fill out complaint in00175354, follow these steps: 1. Start by providing your personal information such as your name, contact details, and address. 2. Clearly state the purpose of your complaint and provide a brief description of the problem or issue you are facing. 3. Include any relevant supporting documents or evidence that can strengthen your complaint. 4. Provide details of any previous attempts or conversations you had regarding the issue, including dates and names of individuals involved. 5. Clearly state your desired resolution or outcome for the complaint. 6. Sign and date the complaint form. 7. Make a copy of the complaint for your records. 8. Send the completed complaint form to the appropriate authority or department responsible for handling such complaints.

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