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Get CMS-2786R. CMS Form 10069 Medicare Waiver Demonstration Application - Cms

) MEDICAID I.D. NO. K1 K2 Form Approved OMB Exempt PART I Life Safety Code, New and Existing PART IV Waiver Recommendation Form Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. (A) MULTIPLE CONSTRUCTION (BLDGS) 2. NAME OF FACILITY 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A. (All required areas are sprinklered) A. BUILDING B. WING C. FLOOR.

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