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* 1. Facility Name

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* 2. Medicare Provider Number (PA starts with 39 or 73; DE starts with 08)

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* 3. First and last name of person completing this form?

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* 4. Email contact for the person completing the survey

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* 5. Reporting Month

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* 6. QAPI Meeting Date

Date

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* 7. QAPI -- We have patients, family members, or caregivers Subject Matter Experts (SMEs) participated in your QAPI meeting?

T