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DEPARTMENT OF HEALTH AND HUMAN SERVICES01/31/2012FORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 09380391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION
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The 0104 form approved is a tax form used for reporting income by individuals in certain jurisdictions, often referring to state income tax returns.
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