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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES01/31/2012FORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 09380391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION

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e 0015 is a specific electronic form used to report certain financial or compliance information to regulatory authorities.

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e 0015 requires reporting specific financial data, compliance metrics, and other relevant information as specified by the regulatory authority.

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