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PRINTED: 09/26/2017 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION

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in00238718 and in00239027 are specific forms used for reporting certain financial information to tax authorities, typically related to income reporting and tax compliance.

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The forms require reporting information such as total income, deductions, credits, and any other relevant financial data as specified in the form instructions.

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