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PRINTED: 08/11/2023 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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How to fill out form investigation of complaint

01

Start by gathering all necessary information related to the complaint.

02

Fill out the top section of the form with details of the complainant including name, contact information, and any other relevant details.

03

Provide a detailed description of the complaint in the designated section, including dates, times, and any supporting documentation.

04

Indicate any witnesses or additional parties involved in the complaint.

05

Sign the form and submit it to the appropriate department or individual for investigation.

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What is form investigation of complaint?

Form investigation of complaint is a formal process for reporting and resolving complaints or concerns.

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Information such as the nature of the complaint, parties involved, dates, and any supporting documentation must be reported on form investigation of complaint.

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