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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 11/09/2012
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Begin by reading the instructions on the form carefully to understand what information is required.
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Start by filling out the basic information section, including your name, contact details, and any other relevant personal information.
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Next, provide details about the purpose of the visit. If it was a business visit, mention the company name, address, and any other relevant details. If it was a personal visit, provide the reason for the visit, such as a vacation or family gathering.
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Fill in the dates of the visit, including the arrival and departure dates. Be sure to include the year to avoid any confusion.
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Include information about the places you visited during your stay. If it was a business trip, list the company or client names, addresses, and any important meetings or events attended. If it was a personal trip, mention the tourist attractions or specific locations visited.
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Provide details about your accommodations during the visit. Include the name and address of the hotel, rental property, or the person's home where you stayed.
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If applicable, mention any expenses incurred during the visit. This could include transportation costs, accommodation expenses, meals, or any other related expenses.

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