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PRINTED: 05/15/2018 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION
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Form investigation of complaints is a documentation process used to formally address and investigate grievances or complaints raised by individuals or organizations.
Individuals or entities that have experienced an issue or complaint that requires investigation are required to file this form.
To fill out the form, provide detailed information about the complaint, include personal or organizational details, describe the nature of the complaint, and submit any relevant evidence.
The purpose of the form is to provide a structured way to document and process complaints to ensure they are investigated properly and resolved accordingly.
The form must report the complainant’s information, details of the complaint, any evidence supporting the claim, and the desired outcome or resolution.
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