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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:15565010/28/2015FORM

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What is this visit was for?

This visit was for a routine check-up to assess health and wellness.

Who is required to file this visit was for?

Individuals who attend the visit and require documentation for insurance or record-keeping purposes are required to file.

How to fill out this visit was for?

To fill out the visit documentation, provide personal information, the purpose of the visit, and any relevant medical history.

What is the purpose of this visit was for?

The purpose of this visit was for evaluating health, discussing concerns, and possibly receiving treatment.

What information must be reported on this visit was for?

Information such as date of visit, reason for visit, findings, and any treatments or prescriptions must be reported.

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