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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15G44704/17/2015FORM

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How to fill out this visit was for

01

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

02

Provide your personal information such as name, address, and contact details.

03

Fill out any medical history or current health concerns that may be relevant to the visit.

04

Describe the reason for the visit and any symptoms you are experiencing.

05

Include any medications you are currently taking or have taken recently.

06

Answer any additional questions or provide any necessary information requested by the healthcare provider.

07

Review the form for accuracy and completeness before submitting it.

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What is this visit was for?

This visit was for a routine inspection.

Who is required to file this visit was for?

The department supervisor is required to file this visit.

How to fill out this visit was for?

The visit should be filled out electronically on the department's online portal.

What is the purpose of this visit was for?

The purpose of this visit is to ensure compliance with safety regulations.

What information must be reported on this visit was for?

The information that must be reported includes date of visit, findings, corrective actions taken.

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