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PRINTED: 09/18/2019 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:CANNON LIVING CENTER, THE (X4)

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2. Start by filling out your personal information, such as your name, address, and contact details, in the designated sections of the form.
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5. Make sure to provide all the requested details, including any supporting documents or attachments that may be required.
6. Double-check your responses for any errors or omissions before submitting the form.
7. Once you have finished filling out the form, sign and date it as instructed.
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