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PRINTED: 06/09/2014 FORM APPROVED DEPARTMENT 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 ci - 0128?
CI - 0128 is a form used for reporting income and expenses for tax purposes.
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Information such as income sources, expense categories, and totals must be reported on CI - 0128.
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