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PRINTED: 10/28/2019 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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The printed 1028 form approved is a standardized tax form used for reporting specific financial and tax-related information to the relevant authorities.

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Information that must be reported on the printed 1028 form approved includes personal identification details, income sources, applicable deductions, and any other financial information required by the tax authority.

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