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PRINTED: 12/06/2018 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 printed 1219 department is a tax form used to report income received from miscellaneous sources. It is used to report income that is not reported on a W-2 or 1099 form.

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