Get the free printed: 6/23/2021 form approved omb no. 0938-0391 ...
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Printed: 05/12/2021
Form Approved OMB
No. 09380391Department of Health & 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 623 form approved is a form used for reporting certain financial information to the relevant authorities.
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