Form Dr 416 is an information form used by doctors in Quebec to document a patient's allergies. The form is in French, and all of the instructions are included on the form itself. The form is fairly simple to fill out, and it is important that all of the information is accurate so that patients can receive proper care. The form can be used to document both food allergies and other types of allergies. It is important for patients to inform their doctor about any allergies they have, as this information can help keep them safe.
Question | Answer |
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Form Name | Form Dr 416 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | fl dr 416 form, florida dr 416 form, dr 416 disability form, florida total permanent |
PHYSICIAN’S CERTIFICATION OF
TOTAL AND PERMANENT DISABILITY
R. 11/12
Rule
Florida Administrative Code
Effective 11/12
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, a physician licensed pursuant to Chapter 458 or Chapter 459, |
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Florida Statutes, hereby certify that |
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Miss |
Ms. |
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Name of |
totally and permanently disabled person |
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Social Security Number* |
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, is totally and permanently disabled as of January 1, |
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due to the following mental or |
physical condition(s): |
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Quadriplegia
Paraplegia
Hemiplegia
Legal blindness
Other total and permanent disability requiring use of a wheelchair for mobility
Check here if patient is totally or permanently disabled but does not require a wheelchair for mobility.
It is my professional belief the above condition(s) render |
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totally and permanently disabled and the foregoing statements |
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are true, correct, and complete to the |
best of my knowledge and professional belief. |
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Address: (print) |
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Florida Board of Florida Board of Medicine or Osteopathic Medicine license number
Issued on
NOTICE TO TAXPAYER: Each Florida resident applying for a total and permanent disability exemption must present to the county property appraiser, on or before March 1 of each year, a copy of this form or a letter from the United States Department of Veterans Affairs or its predecessor. Each form is to be completed by a licensed Florida physician.
NOTICE TO TAXPAYER AND PHYSICIAN: Section 196.131(2), Florida Statutes, provides that any person who knowingly and willfully gives false information for the purpose of claiming homestead exemption commits a misdemeanor of the first degree, punishable by a term of imprisonment not exceeding 1 year or a fine not exceeding $5,000, or both.
*Disclosure of your social security number is mandatory. It is required by sections 196.011(1) and 196.101(5), Florida Statutes. The social security number will be used to verify taxpayer identity information and homestead exemption information submitted to property appraisers.