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PRINTED: 11/17/2023 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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The information that must be reported includes personal details, income amount, business expenses, and any applicable tax deductions related to the self-employment income.
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