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FOR BHF USELL1 2021STATE OF ILLINOIS DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES FINANCIAL AND STATISTICAL REPORT (COST REPORT) FOR LONGER CARE FACILITIES (FISCAL YEAR 2021) I.DPH License ID Number:

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Administrator type or print is a form used to report information about administrators of a company.

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Administrators or authorized representatives of a company are required to file administrator type or print.

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Information such as the names, contact details, and roles of administrators must be reported on administrator type or print.

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