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PRINTED: 10/24/2019 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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Obtain a recertification form from the appropriate department or agency.
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Fill out the form completely with accurate information.
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Provide any required documentation or proof to support your recertification or complaint.
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Submit the form according to the specified instructions, whether it be online, in person, or by mail.
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Who needs a recertification and complaint?

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Individuals who are seeking to renew or update their certification or status.
02
Individuals who have a complaint or concern that needs to be addressed by a specific department or agency.
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A recertification is the process of renewing a certification or license, while a complaint is a formal allegation of wrongdoing or violation.
Individuals or organizations holding a certification or license are required to file a recertification. Anyone who has information about misconduct can file a complaint.
To fill out a recertification, you need to provide updated information and documentation. To file a complaint, you need to submit a formal written statement detailing the alleged misconduct.
The purpose of a recertification is to ensure that individuals or organizations continue to meet the requirements for holding a certification or license. The purpose of a complaint is to address and investigate alleged misconduct.
A recertification may require updated contact information, proof of continued education, and any relevant work experience. A complaint must include details of the alleged misconduct, names of involved parties, and supporting evidence.
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