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PRINTED: 06/02/2022 FORM APPROVED OMB NO 09380391DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1)(X2) MULTIPLEPROVIDER/SUPPLIER/CIA

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How to fill out name of provider

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Start with the first name of the provider

02

Follow with the last name of the provider

03

If applicable, include any credentials or titles after the last name

Who needs name of provider?

01

Any individual or organization that requires information about a specific provider, such as healthcare professionals, insurance companies, or patients

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What is the name of provider?

The name of the provider refers to the legal name of the individual or organization that is offering services or products.

Who is required to file the name of provider?

Any entity or individual that provides services or products and is subject to regulatory or reporting requirements must file the name of the provider.

How to fill out the name of provider?

To fill out the name of the provider, one should enter the complete legal name of the business or individual as registered with the appropriate authorities.

What is the purpose of the name of provider?

The purpose of collecting the name of the provider is to ensure accountability, regulatory compliance and facilitate proper documentation and reporting.

What information must be reported on the name of provider?

The information that must be reported includes the legal name, business address, tax identification number, and any relevant licensing information.

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