Intakes TN00026222, TN00027233 - health state tn 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the provider identification number in the designated field. This is crucial for tracking and referencing your submission.
3. Fill in the name of the provider or supplier along with their complete address, including street, city, state, and ZIP code. Ensure accuracy to avoid any processing delays.
4. In the section for survey completion date, input the date when the survey was conducted. This helps maintain a clear timeline of events.
5. Review the summary statement of deficiencies carefully. If applicable, provide corrective actions in relation to each deficiency noted.
6. Finally, ensure that all signatures are completed where required, including that of the laboratory director or representative. This validates your submission.

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