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PRINTED: 04/09/2021
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 1217 is the Department of Tax and Revenue form used to report income and expenses for a specific tax year.
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