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PRINTED: 10/28/2015
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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Printed 1028 form approved is a tax form used by individuals who are self-employed or have income from sources other than wages.
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