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PRINTED: 08×23/2021 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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The 0111 form approved is a tax form used for reporting specific financial information to the IRS, often related to income or deductions.
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