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PRINTED: 06/20/2023 FORM APPROVED Re elation & Licensing Administration Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(XL) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:HCA0079 NAME OF PROVIDER

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The 0629 form is a specific document used to report certain financial or tax-related information, and it must be approved by the relevant tax authority before submission.

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Required information typically includes identification details, financial data, tax identification numbers, and any other relevant information as specified by the filing guidelines.

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