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02/02/2018PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION
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Form W-104 is a tax form used for reporting income and other tax-related information to the IRS, typically associated with specific types of taxable income.
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Information that must be reported on Form W-104 includes the amount of income received, payer details, and any relevant tax identification numbers.
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