Form 4023 PDF Details

Form 4023 is a new Form for the 2014 Tax Season. This form is used to report certain information about contributions made to certain charitable organizations. The IRS has provided detailed instructions on how to complete this form, and it is important that taxpayers comply with these instructions to avoid any penalties. In this blog post, we will provide an overview of Form 4023 and discuss some of the key things taxpayers need to know in order to complete it correctly. We will also provide a link to the IRS's website where taxpayers can find more information about this form. Thanks for reading!

QuestionAnswer
Form NameForm 4023
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesprintable pre op clearance form, pre op clearance form pdf, pre op surgery forms, surgical clearance form

Form Preview Example

PREOPERATIVE MEDICAL EVALUATION

AND CLEARANCE FOR SURGERY

Fax to (786) 596-3676

Baptist Pre-Surgery Office

Date of Examination___________________

Must be completed: G 3 Days G 7 Days (MAJOR SURGERY)

before surgery

Patient Name _________________________________________________ Age________ Sex ________

Date of Surgery__________________ Location of Surgery Baptist Hospital

Physician _________________________________ Surgeon __________________________________

Specialist _________________________________ Specialist _________________________________

Proposed Surgical Procedure ____________________________________________________________

Indication for Surgery __________________________________________________________________

Medical Problems

GNone

1._______________________________________________________________________________

2._______________________________________________________________________________

3._______________________________________________________________________________

4._______________________________________________________________________________

5._______________________________________________________________________________

Cigarettes ___________________________________________ Alcohol ________________________

Medications _________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Allergies G None ____________________________________________________________________

Prior Surgery G None ________________________________________________________________

____________________________________________________________________________________

Previous Surgical Complications G None

__________________________________________________

History of Excessive Bleeding

G None

G Patient

G Family

Physical Exam:

 

 

 

BP _____________ HR ____________

Ht ____________

Wt ____________ LMP ___________

HEENT _____________________________________________________________________________

Neck _______________________________________________________________________________

Chest and Lungs _____________________________________________________________________

Heart _______________________________________________________________________________

Abdomen ___________________________________________________________________________

Extremities __________________________________________________________________________

Neuro/ Mental Status __________________________________________________________________

Other Pertinent Findings:________________________________________________________________



*09200B4023*

Page 1 of 2 ! Form #4023 (Rev. 12/08)

PREOPERATIVE MEDICAL EVALUATION

AND CLEARANCE FOR SURGERY

Pertinent Diagnostic Data: See attached ASA Recommendations

Not Indicated Preop Tests

Date

Results

G

EKG

____________

_________________________________________

G

CXR

____________

_________________________________________

G

U/A

____________

_________________________________________

G

CBC

____________

_________________________________________

G

Chemistry

____________

_________________________________________

G

PT/PTT

____________

_________________________________________

G

Cardiac Echo

____________

_________________________________________

G

Stress/Cath

____________

_________________________________________

G

HgbAlC (Diabetic patients) ____________

_________________________________________

G

SCrCl (PCN allergy)

____________

_________________________________________

Other

___________

____________

_________________________________________

Recommendations:

GThe patient is not in optimal medical condition for the proposed surgery for the following reason(s):

_________________________________________________________________________________

_________________________________________________________________________________

GDelayed - Surgery should be delayed for the following reason(s):

_________________________________________________________________________________

_________________________________________________________________________________

GThe patient is in optimal medical condition to undergo surgery at this time

Further Recommendations: ___________________________________________________________

_________________________________________________________________________________

Instructions to patients: _________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

 

Signature__________________________________________________

 

MD Name _________________________________________________



Specialty_________________________________ Date ____________

 

*09200B4023*

Page 2 of 2 ! Form #4023 (Rev. 12/08)

How to Edit Form 4023 Online for Free

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Step 1: First of all, open the editor by clicking the "Get Form Button" in the top section of this webpage.

Step 2: After you launch the editor, you'll see the document prepared to be completed. Besides filling out various blanks, you might also do other sorts of things with the form, particularly putting on your own text, modifying the original textual content, adding illustrations or photos, placing your signature to the form, and more.

This form will require you to type in some specific information; to guarantee accuracy and reliability, you need to take note of the guidelines just below:

1. You need to complete the surgery clearance form properly, therefore be attentive while filling out the parts comprising these blanks:

pre op surgery forms completion process clarified (part 1)

2. After this section is done, you have to insert the required details in Medications, Allergies G None Prior Surgery G, BP HR Ht Wt LMP, HEENT, Neck, Chest and Lungs, Heart, Abdomen, Extremities, Neuro Mental Status, and Other Pertinent Findings allowing you to move on further.

Guidelines on how to fill in pre op surgery forms part 2

3. The next stage is normally hassle-free - fill in all the empty fields in G G G G G G G G G G, EKG, CXR, CBC, Chemistry, PTPTT, Cardiac Echo, StressCath, HgbAlC Diabetic patients, SCrCl PCN allergy, Other, Recommendations G The patient is, and G Delayed Surgery should be in order to finish this segment.

Part no. 3 of completing pre op surgery forms

4. This particular paragraph comes with these particular empty form fields to fill out: G Delayed Surgery should be, G The patient is in optimal, Instructions to patients, Signature, MD Name, and Specialty Date.

Stage no. 4 for submitting pre op surgery forms

It is easy to make an error while filling in the Specialty Date, for that reason ensure that you go through it again before you'll finalize the form.

Step 3: Look through what you've inserted in the blanks and press the "Done" button. Right after getting afree trial account with us, you will be able to download surgery clearance form or email it immediately. The PDF file will also be accessible in your personal cabinet with all of your changes. When using FormsPal, you can easily fill out documents without needing to be concerned about data incidents or entries being distributed. Our protected software ensures that your private data is kept safe.