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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 155230

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1. Begin by entering the date in the designated space on the form. You can write the date in the specified format provided.
2. Fill in your full name in the appropriate section. Make sure to use your legal name and avoid any abbreviations.
3. Provide your current address. This should include the street name, number, and any additional details if necessary.
4. Enter your city, state, and zip code in the respective fields. Double-check the accuracy to ensure it matches your current location.
5. If applicable, include your phone number and email address in the provided spaces. These details may be used for further communication if required.
6. Some forms might require additional information such as your social security number, date of birth, or employment details. Fill in these sections accurately, following the instructions provided.
7. Review the form for any errors or missing information. Make sure all fields are completed correctly and legibly.
8. Once you have verified all the information, sign and date the form as required. Your signature indicates that all the details provided are true and accurate to the best of your knowledge.

Who needs 2050 Chester Blvd?

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