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Get CMS-116 2015

Lled Nursing Facility/ Nursing Facility 28 Tissue Bank/Repositories 29 Other (Specify) (List times during which laboratory testing is performed in HH:MM format) If MONDAY TUESDAY WEDNESDAY THURSDAY testing 24/7 Check Here FRIDAY SATURDAY FROM: TO: (For multiple sites, attach the additional information using the same format.) V. MULTIPLE SITES (must meet one of the regulatory exceptions to apply for this provision in 1-3 below) Are you applying for a single site CLIA certificate to cove.

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