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PRINTED: 04/20/2018 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 0502 - form is a tax form used for reporting specific information to the IRS.

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Certain individuals or entities, as determined by the IRS, are required to file printed 0502 - form.

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