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04/07/2020PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION

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Start by entering the date of the visit in the specified field.

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Provide your personal information including name, address, and contact details.

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Fill out any necessary medical history or relevant information about your visit.

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This visit was for individuals seeking medical attention or consultation from a healthcare provider.

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What is this visit was for?

This visit is for conducting a routine inspection of the premises.

Who is required to file this visit was for?

The owner or manager of the premises is required to file this visit.

How to fill out this visit was for?

The visit should be documented with details of the inspection, findings, and any corrective actions taken.

What is the purpose of this visit was for?

The purpose of this visit is to ensure compliance with safety regulations and maintain a safe working environment.

What information must be reported on this visit was for?

Information on any violations, hazards, and measures taken to address them must be reported.

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