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PRINTED: 10/23/2023 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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A formal statement filed by an individual or organization regarding an issue or concern relating to federal or state regulations.
Any individual or organization that believes there has been a violation of federal or state regulations can file a complaint.
The complaint can be filled out by providing specific details of the alleged violation, supporting documentation, and contact information.
The purpose of the complaint is to bring attention to a potential violation of regulations and initiate an investigation or enforcement action.
The complaint must include details of the alleged violation, supporting evidence, contact information of the filer, and any other relevant information.
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