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PRINTED: 12/03/2020 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 1203 form approved is a form used for reporting certain types of income, such as awards, prizes, or taxable fringe benefits.
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