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PRINTED: 01/26/2024
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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01
Begin by entering the date of the visit in the designated field.
02
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03
Indicate the purpose of the visit and any specific areas that were discussed.
04
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What is this visit was for?
This visit was for a routine check-up and assessment of health status.
Who is required to file this visit was for?
Individuals participating in the program or required healthcare plan are required to file this visit.
How to fill out this visit was for?
To fill out this visit, complete the required forms detailing personal information, reason for the visit, and healthcare provider details.
What is the purpose of this visit was for?
The purpose of this visit is to ensure health maintenance and address any existing medical concerns.
What information must be reported on this visit was for?
Information that must be reported includes patient's personal information, visit date, reason for the visit, and any treatments given.
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