Form Cms-3070h - Icf/iid Deficiencies Report Page 2

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0062
DEFICIENCIES
COMMENTS
1. DATA TAG NO.
2. CoP/STND NO.
FORM CMS-3070H (03/13)
2

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