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PRINTED: 08/02/2018
FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA
IDENTIFICATION
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How to fill out state licensure survey and
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What is state licensure survey?
State licensure survey is a process in which healthcare providers are required to report information about their licenses to practice in a particular state.
Who is required to file state licensure survey?
Healthcare providers such as doctors, nurses, and therapists are typically required to file state licensure surveys.
How to fill out state licensure survey?
Healthcare providers can typically fill out state licensure surveys online through a state's licensing board website.
What is the purpose of state licensure survey?
The purpose of state licensure survey is to ensure that healthcare providers are properly licensed to practice in a particular state.
What information must be reported on state licensure survey?
Information that must be reported on state licensure surveys typically includes the provider's name, license number, expiration date, and any disciplinary actions.
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