Get the free printed: 10/16/2014 - form approved omb no. 0938-0391
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PRINTED: 01/24/2016
FORM APPROVEDDivision of Health Service Regulation
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA
IDENTIFICATION NUMBER:ROCKDALE HIGH POINT NORTH AL
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The printed 1016 form is the form used for reporting certain income items related to royalties.
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