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Get HHS CMS-2572 ; 1981-2024

The provider of services, hereby states and declares: 1. That the provider of services has not been adjudged insolvent or bankrupt in a State or Federal court; and 2. That a court proceeding to make a judgement of bankruptcy or insolvency with respect to the provider of services is not pending in a State or Federal court. In addition, the provider of services agrees to inform the Secretary of Health and Human Services, through the Centers for Medicare & Medicaid Services Regional Office, immedi.

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