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PRINTED: 06/11/2020 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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What is this visit included form?

This visit included form is a document that lists all the details of a visit, including purpose, duration, and any expenses incurred.

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Any individual or organization that has gone on a visit and incurred expenses related to that visit is required to file this form.

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