Are you looking for information about Sdmc Form 220 B? This document is filled out by legal representatives to represent an organization in a nonadversarial context, mostly related to settling disputes and other matters. In this blog post, we will cover all the important aspects of Sdmc Form 220 B, what it entails, how it's used and the necessary steps when filling it out. So if you're dealing with an issue that requires this form then read on!
| Question | Answer |
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| Form Name | Sdmc Form 220 B |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | sdmc form 220 b, Consults, MHL, sdmc forms download |
**DO NOT |
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(REV. 07/2013) |
**DO NOT STAPLE FORMS** |
Page 1 of 3 |
SDMC FORM |
SURROGATE |
SUPPLEMENTAL MEDICAL |
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PROCEEDING FOR THE REVIEW OF THE NEED FOR |
INFORMATION |
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SURROGATE |
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Declaration # (SDMC Use Only) |
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(Patient’s Name) |
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ALL QUESTIONS MUST BE ANSWERED TO PREVENT A DELAY IN PROCESSING THE CASE
1a. Current medications, dosages, frequency and mode of intake:
1b. List any drugs requiring frequent blood level monitoring. (Include copy)
2.Any known allergies:
3. Annual physical examination:(Must include copy)
(Date)
Abnormal findings:
4.Most recent EKG:
5.Most recent Chest
6.Most recent laboratory tests:
(Date)
(Date)
(Date)
(Include copy, if available) (Include copy, if available) (Include copy, if available)
7. |
Has there been a second opinion? If so what type? |
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Capacity |
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Best Interest |
**DO NOT |
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(REV. 07/2013) |
**DO NOT STAPLE FORMS** |
Page 2 of 3 |
SDMC FORM |
8.List any cardiac or pulmonary condition(s):
9.List any major illness, surgery and/or hospitalizations in the last year:
10.List any other known physical conditions:
11. |
Has this patient had general anesthesia before? |
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Yes |
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No |
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Unknown |
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Date of most recent general anesthesia: |
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Any history of adverse reactions to general anesthesia? |
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Yes |
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No |
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Unknown |
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*IV sedation and MAC are not considered general anesthesia for SDMC cases.
If yes, describe:
12.MHL Article 80 requires the patient to be present at the hearing. Is there any medical condition that
would prevent the patient from attending the hearing? |
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Yes |
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No |
If yes, explain:
**DO NOT |
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(REV. 07/2013) |
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**DO NOT STAPLE FORMS** |
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Page 3 of 3 |
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SDMC FORM |
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13. |
Is the requested procedure(s) scheduled? |
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Yes |
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No |
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If yes, date: |
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If no, when is the anticipated scheduled date? |
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14. |
Has the patient been reviewed by SDMC previously? |
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Yes |
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No |
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Unknown |
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If yes, answer the following (if known): |
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a.Date most recent SDMC approved procedure performed:
b.Procedure(s) previously requested:
c.Results of procedure(s):
15.If the patient has been transferred to a healthcare facility other than their residence, please provide the following information:
Facility Name:
Facility Address:
Facility Contact Person: Name:
Contact’s Phone #: ( ) |
Patient’s Room #: |
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16. The above information and statements are to the best of my knowledge truthful and complete.
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Print Name Clearly |
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Signature |
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Title |
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Date |
Work Phone: ( |
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Work Cell: ( |
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Work Fax: ( |
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PLEASE REMEMBER TO ATTACH:
Consults, progress notes, annual physical exam, results of diagnostic tests and other documentation related to the proposed major medical treatment(s) being requested.