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Get Wisconsin Dqa Form F 62495

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62495 Rev. 12/11 STATE OF WISCONSIN COMPLIANCE STATEMENT Completion and submission of this form is required by COMM 61. Gov or contact your DQA Engineer Hospitals Nursing Homes / CBRFs Telephone FAX Tom Ankeny Richard Batchelder Henry Kosarzycki 608-264-7743 414-220-5306 414-227-4951 608-264-9847 Ganesh Shrestha Lynn Wallace 414-227-2004 Romaine Anderson David Beyer Kevin Derenne 715-.

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