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PRINTED: 03/10/2017 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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Printed 0626 refers to a specific tax form used by the Department of Revenue for reporting particular information related to income, deductions, or other financial items required by the department.

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