Form 3870 PDF Details

In order to accurately report your taxes, you are required to complete Form 3870. This form is used to calculate and report the alternative minimum tax (AMT). The AMT is a separate tax system that determines whether you have paid enough taxes during the year. If you owe additional taxes under the AMT, you will need to pay them using Form 1040-X. Completing Form 3870 can be complex, so it is important to seek help if needed. The IRS offers free resources to help taxpayers understand and complete this form. For more information, visit the IRS website.

QuestionAnswer
Form NameForm 3870
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesCIED, form 3870, irs form 3870, EMI

Form Preview Example

PERIOPERATIVE PACEMAKER / ICD CHECKLIST

This checklist to be placed in the patient’s medical record

PREOP NURSE CHECKLIST (to be completed by the Preop Nurse)

£

Patient contacted and device identiied

 

 

£

CIED Clinical Specialist contacted (x49642) Date:

Name:

 

£

CIED Clinical Specialist notiied of date and time of surgery, anatomical location, anticipated use of electrocautery, litho-

tripsy and/or any other EMI (prone position, bone hammers / saws, mechanical ventilation, etc.)

 

Signature:

Date:

Time:

 

 

 

 

PERIOPERATIVE MANAGEMENT CHECKLIST (To be completed by CIED Clinical Specialist)

Manufacturer: ______________________________________________________

Date Implanted: ________________________

Location: __________________________________________________________

Date last interrogated: ___________________

Is there an alert status on the device? £ No £ Yes _______________________________________________________________

Indication for device placement: ________________________________________________________________________________

Device Type: £ Single chamber pacemaker

£ Dual chamber AICD / pacemaker

 

£ Dual chamber pacemaker

£ Biventricular AICD / pacemaker

 

 

 

 

 

PACEMAKER

 

PRE-OP

CHANGED TO

POST-OP

Mode

Mode

 

Leads: £ Unipolar £ Bipolar

 

 

 

 

 

Set Pacing Rate

Rate

 

Output (pacing threshold)

Output (pacing threshold)

 

£Magnet response enabled at rate of: _________

Adaptive Mode: £ On £ Off £ NA

Rate: _________

£ On £ Off £ NA

Adaptive Mode: £ On £ Off £ NA

Rate: _________

Underlying intrinsic Rate: _________

Rhythm: _________

 

Underlying intrinsic Rate: _________

Rhythm: _________

Pacemaker Dependent: £ Yes £ No

 

 

£ Unchanged

 

Battery Life: £ Adequate £ End of life

 

 

 

 

 

 

 

ICD (IMPLANTABLE CARDIOVERTER DEFIBRILLATOR)

 

ICD Function: £ On £ Off £ NA

 

£ On £ Off £ NA

ICD Function: £ On £ Off £ NA

 

£Magnet response enabled (anti-tachyarrhythmia therapy function will be disabled with magnet placement)

ICD Discharge frequency

£less than once per mo £ greater than once per mo Date of last discharge: ___________________

Pre-Op interrogation of device revealed normal function and battery life. Parameters set / changed as documented.

Signature: __________________________________________

Date: ______________________________ Time: __________

Post-Op interrogation of device revealed normal function and battery life. Parameters set / changed as documented.

Signature: __________________________________________

Date: ______________________________ Time: __________

Notes: ____________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

________________________________________________

____________________________________________________

_______________________

_________

Electrophysiology Physician’s Name (Print)

Signature

Date

Time

*02400B3870*

*02400B3870*

Form #3870 (Rev. 7/14)