Form Hea 4713 PDF Details

Form Hea 4713 is an essential piece of tax paperwork for any business owner. This form must be filed by April 15th of every year, and it outlines the amount of taxes your business owes for the previous year. Failing to file this form on time can result in hefty fines and penalties, so it's important to make sure you understand how to complete it correctly. This blog post will provide a step-by-step guide to filling out Form Hea 4713, so you can make sure your business is compliant with the IRS. Stay safe and stay organized this tax season - read on!

QuestionAnswer
Form NameForm Hea 4713
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdisclosure, Referral, eye doctor prescription template, glasses prescription form pdf

Form Preview Example

 

 

 

Ohio Department of Health

 

 

 

 

 

 

 

 

Eye Specialist Report

 

 

 

 

 

School Screening Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child’s Name

 

 

 

 

 

 

 

Date of Referral

 

 

 

 

 

 

 

 

 

 

 

 

School

 

 

 

 

 

 

 

Grade

 

 

 

 

 

 

 

 

 

 

Reason for referral (test failed or type of symptom)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School Screening visual acuity

without glasses

with glasses

 

 

 

 

 

 

 

 

R___________

L ___________

R___________

L ___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eye Specialist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Distance Visual Acuity

without correction

with current prescription

with new prescription

 

 

R___________

L ___________

R___________

L ___________

R___________ L ___________

 

 

 

 

 

 

 

 

 

 

 

Summary of vision problems and diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recommendations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional instructions for teacher

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is further treatment necessary?

Yes

No

 

I wish to see the child again.

Yes

No

 

 

 

 

 

If yes, specify

 

 

 

If yes, when?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please return form to

 

 

 

From

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eye Specialist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

City

State

ZIP

Date

This form is intended for the sole use of the intended recipient and may contain privileged, sensitive, or protected health information. If you are not the intended recipient, be advised that the unauthorized use, disclosure, copying, distribution or action taken in reliance on the contents of this communication is prohibited.

HEA 4713 (Rev 6/07)