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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:15510409/22/2017FORM

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To fill out the complaint IN00236217, follow the steps below: 1. Start by writing your full name, address, and contact information at the top of the complaint form. 2. Provide the details of the complaint. Include dates, times, locations, and any other relevant information. 3. Clearly state the reason for the complaint and what actions you would like to be taken to resolve the issue. 4. Attach any supporting documents or evidence, such as photographs or receipts, that can strengthen your case. 5. Sign and date the complaint form before submitting it to the appropriate authority or organization. 6. Keep a copy of the complaint for your records. 7. Follow up with the relevant party to inquire about the progress of the complaint and seek resolution.

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