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PRINTED: 3/26/2021 FORM APPROVEDState of GA, Healthcare Facility Regulation Division STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:ALC000552(X2)

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Start by providing your full name in the designated field.

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Next, input your address, including street address, city, state, and zip code.

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Who needs contact information for filing?

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Anyone filing official documents or forms may need to provide contact information.

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What is contact information for filing?

Contact information for filing is the information required to be submitted in order to reach the individual or organization responsible for filing.

Who is required to file contact information for filing?

Any individual or organization who is responsible for submitting filings is required to provide contact information for filing.

How to fill out contact information for filing?

Contact information for filing can be filled out by providing details such as name, address, phone number, and email.

What is the purpose of contact information for filing?

The purpose of contact information for filing is to ensure that the responsible party can be contacted regarding any issues or inquiries related to the filing.

What information must be reported on contact information for filing?

Contact information for filing must include details such as name, address, phone number, and email of the responsible party.

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