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Get and Sign Florida Certification Civil Rights Information Request Form 2017-2022

Get and Sign Florida Certification Civil Rights Information Request Form 2017-2022

Use the form 0006 pdf 2017 template to simplify high-volume document management.

Part A program must receive a civil rights clearance from OCR. Complete all fields and return this form with the required policies and procedures to your State Health Department along w ith your other Medicare application materials. I. Healthcare Provider Information CMS Medicare Provider Number Name of Facility Address Street Number and Name City or Town State or Province Admin istrator s Name Telephone FAX Type of Facility Zip Code Contact Person TOO E-mail Number of employees Reason fo r...
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