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Get CMS-2786Y 2007

Retarded SMALL FSES Form Approved OMB No. 0938-0242 1. (A) PROVIDER NO. 1. (B) MEDICAID I.D. NO. K1 K2 PART III Chapter 7-101A Fire Safety Evaluation System for Board & Care (Optional) 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.

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