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!
Question | Answer |
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Form Name | Form Hea 4713 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | disclosure, Referral, eye doctor prescription template, glasses prescription form pdf |
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Ohio Department of Health |
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Eye Specialist Report |
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School Screening Information |
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Child’s Name |
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Date of Referral |
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School |
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Grade |
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Reason for referral (test failed or type of symptom) |
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School Screening visual acuity |
without glasses |
with glasses |
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R___________ |
L ___________ |
R___________ |
L ___________ |
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Eye Specialist |
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Distance Visual Acuity |
without correction |
with current prescription |
with new prescription |
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R___________ |
L ___________ |
R___________ |
L ___________ |
R___________ L ___________ |
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Summary of vision problems and diagnosis |
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Recommendations |
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Additional instructions for teacher |
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Is further treatment necessary? |
■ Yes |
■ No |
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I wish to see the child again. |
■ Yes |
■ No |
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If yes, specify |
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If yes, when? |
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Please return form to |
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From |
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Eye Specialist |
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Address |
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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)