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PRINTED: 01/17/2017 FORM APPROVED Division of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(XI) PROVIDER/SUPPER/CIA IDENTIFICATION NUMBER:(OZ) MULTIPLE CONSTRUCTION A.

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Obtain the xi providersuppuerclia form from the appropriate source.

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Clearly print your personal information such as name, address, and contact details on the form.

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Provide detailed information about the services or products you offer as a provider.

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What is xi providersuppuerclia?

Xi providersuppuerclia is a form used for reporting provider supplier related information.

Who is required to file xi providersuppuerclia?

All providers and suppliers are required to file xi providersuppuerclia.

How to fill out xi providersuppuerclia?

Xi providersuppuerclia can be filled out online or by submitting a paper form with the required information.

What is the purpose of xi providersuppuerclia?

The purpose of xi providersuppuerclia is to ensure transparency and accuracy in reporting provider supplier information.

What information must be reported on xi providersuppuerclia?

Xi providersuppuerclia requires reporting of contact information, services provided, and any changes in provider supplier status.

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