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PRINTED: 11/15/2019 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:SOUTHERN MANOR REST HOME (X4)
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Printed 1115 form approved is a form used for reporting information about approved waivers for Medicaid and CHIP programs.
State Medicaid agencies are required to file printed 1115 form approved.
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The purpose of printed 1115 form approved is to report information about approved waivers for Medicaid and CHIP programs to the relevant authorities.
Information such as details of approved waivers, program goals, evaluation plans, and other relevant information must be reported on printed 1115 form approved.
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