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PRINTED: 10/24/2019 FORM APPROVEDState of GA, Healthcare Facility Regulation Division STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:025R1286(X2)

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What is 025-r-1286?

025-r-1286 is a form used for reporting financial information to the appropriate regulatory agency.

Who is required to file 025-r-1286?

All individuals or entities who meet the criteria set by the regulatory agency must file 025-r-1286.

How to fill out 025-r-1286?

To fill out 025-r-1286, you need to provide accurate financial information in the designated sections of the form as per the instructions provided by the regulatory agency.

What is the purpose of 025-r-1286?

The purpose of 025-r-1286 is to provide transparency and accountability by disclosing financial information to the regulatory agency for monitoring and regulatory purposes.

What information must be reported on 025-r-1286?

Information such as income, expenses, assets, liabilities, and other financial details as required by the regulatory agency must be reported on 025-r-1286.

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