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Get Form 4101
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How to fill out the Form 4101 online
Filling out Form 4101 is an essential step for individuals looking to register with a family doctor. This guide will help you understand each section of the form, ensuring you complete it accurately and efficiently.
Follow the steps to correctly complete the Form 4101 online.
- Click 'Get Form' button to obtain the form and open it in the editor.
- In section 1(a), provide the last name and first name of your family doctor. If your doctor belongs to a family medicine group, complete section 1(b) with the name and reference number of that group.
- Proceed to section 2 and enter the health insurance number, date of birth, and mailing address of the insured person. Fill in the phone numbers for both home and work, selecting the appropriate sex option.
- In section 3, identify the usual service point's name and number.
- Section 4 requires the insured person to declare the accuracy of the information provided. The insured person should sign and date this section.
- Have the insured person or their representative, if applicable, complete section 6 with consent for accessing personal information.
- In section 7, the family doctor must sign and date, confirming their acceptance of the registration.
- Once all sections are completed and signed, you can save the changes, download, print, or share the form accordingly, ensuring not to submit the paper version to the Régie.
Complete your Form 4101 online today and ensure a seamless registration with your family doctor.
Form 4101 1R is a document produced by NGB, the National Guard Bureau. It's used to provide evidence of military status to employers, insurance companies, and other specified organizations. The form proves that the individual who presents it is actively engaged in the service of their country.
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