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PRINTED: 02/17/2023 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:BROOKSHOWELL HOME (X4) ID PREFIX

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How to fill out a relicensure and complaint

01

Gather all necessary documents and information required for relicensure or complaint form.

02

Fill out the form accurately and completely, following any specific instructions provided.

03

Ensure that all required signatures are obtained and any supporting documentation is included.

04

Submit the completed form and any additional materials to the appropriate licensing board or regulatory agency.

Who needs a relicensure and complaint?

01

Individuals who are seeking to renew or maintain their professional license or certification would need relicensure.

02

Individuals who have experienced a problem or issue with a professional in a licensed field may need to file a complaint.

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What is a relicensure and complaint?

A relicensure and complaint is a process where an individual or organization needs to renew their license or certification and report any complaints or issues.

Who is required to file a relicensure and complaint?

Anyone holding a license or certification in a specific field is required to file a relicensure and complaint.

How to fill out a relicensure and complaint?

To fill out a relicensure and complaint, one must provide all required information accurately and submit it by the deadline.

What is the purpose of a relicensure and complaint?

The purpose of a relicensure and complaint is to ensure that licensed individuals or organizations are current with their qualifications and to address any complaints or issues that may arise.

What information must be reported on a relicensure and complaint?

The information to be reported on a relicensure and complaint may vary but typically includes personal information, license or certification details, and any complaints or issues.

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