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.
Question | Answer |
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Form Name | Form 3870 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | CIED, form 3870, irs form 3870, EMI |
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 |
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£ |
CIED Clinical Specialist contacted (x49642) Date: |
Name: |
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£ |
CIED Clinical Specialist notiied of date and time of surgery, anatomical location, anticipated use of electrocautery, litho- |
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tripsy and/or any other EMI (prone position, bone hammers / saws, mechanical ventilation, etc.) |
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Signature: |
Date: |
Time: |
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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 |
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£ Dual chamber pacemaker |
£ Biventricular AICD / pacemaker |
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PACEMAKER |
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CHANGED TO |
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Mode |
Mode |
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Leads: £ Unipolar £ Bipolar |
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Set Pacing Rate |
Rate |
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Output (pacing threshold) |
Output (pacing threshold) |
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£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: _________ |
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Underlying intrinsic Rate: _________ |
Rhythm: _________ |
Pacemaker Dependent: £ Yes £ No |
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£ Unchanged |
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Battery Life: £ Adequate £ End of life |
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ICD (IMPLANTABLE CARDIOVERTER DEFIBRILLATOR) |
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ICD Function: £ On £ Off £ NA |
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£ On £ Off £ NA |
ICD Function: £ On £ Off £ NA |
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£Magnet response enabled
ICD Discharge frequency
£less than once per mo £ greater than once per mo Date of last discharge: ___________________
Signature: __________________________________________
Date: ______________________________ Time: __________
Signature: __________________________________________
Date: ______________________________ Time: __________
Notes: ____________________________________________________________________________________________________________________
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____________________________________________________ |
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Electrophysiology Physician’s Name (Print) |
Signature |
Date |
Time |
*02400B3870*
*02400B3870* |
Form #3870 (Rev. 7/14) |
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