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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:15529511/21/2017FORM
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Begin by addressing the recipient of the complaint. This can be the company or organization you are filing the complaint against.
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The individual or entity directly impacted by the situation described in the complaint.
Provide detailed information about the issue, including dates, names, and any supporting documentation.
To address and resolve the issue at hand and provide a formal record of the complaint.
Specific details of the incident or situation, names of involved parties, dates, and any supporting evidence.
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