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PRINTED: 01/23/2020 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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It is a residential address.
The property owner or tenant is required to file.
The form must be completed with accurate information about the property.
To report information about the property at that address.
Information such as ownership details, property characteristics, and any changes.
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