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PRINTED: 02/06/2018 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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{"in00252467":"in00252467 is a unique identification number for a specific form or document.", "in00252688":"in00252688 is also a unique identification number for a different form or document."}

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{"in00252467":"The individuals or entities specified in the instructions for the form associated with in00252467.", "in00252688":"The individuals or entities specified in the instructions for the form associated with in00252688."}

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{"in00252467":"Follow the instructions provided on the form associated with in00252467.", "in00252688":"Follow the instructions provided on the form associated with in00252688."}

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{"in00252467":"The purpose of in00252467 is to collect specific information required by the relevant authorities.", "in00252688":"The purpose of in00252688 is also to collect specific information required by the relevant authorities."}

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{"in00252467":"The specific information required by the form associated with in00252467 must be reported.", "in00252688":"The specific information required by the form associated with in00252688 must be reported."}