Get 4163236400

Filling out the 4163236400 form online can seem overwhelming, but with clear guidance, you can complete it accurately. This step-by-step guide will help you navigate each section of the form and ensure all required information is provided.

Follow the steps to fill out the form effectively

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online document editor.
2. In the Patient Information section, enter the medical record number, health card number, and version code. Provide your first and last name, date of birth, and sex by selecting 'M' or 'F'. Fill in your address, city, province, postal code, and contact numbers.
3. Indicate your mobility status by checking the appropriate box—either Walking, Wheelchair, Stretcher, Ambulance, or Other. If applicable, provide information regarding billing, including any insurance or claim numbers.
4. Respond to the safety questions by checking 'YES' or 'NO' for each applicable condition. Include a working diagnosis and list any relevant clinical information.
5. In the Completed Tests and Associated Results section, specify any sites involved in past treatments such as Sinai Health System or Women’s College Hospital. If there’s a history of an allergic reaction to IV contrast, provide details.
6. Complete the Referring Healthcare Provider section by adding the referrer's name, address, weight, height, eGFR, and other required information. Make sure to indicate if an interpreter is needed and specify the language.
7. Finally, ensure the referrer’s signature and date are included. Review the form thoroughly for completeness, as incomplete or unclear forms will not be processed.
8. You can save any changes made, download the form for your records, print it for submission, or share it as required.

Complete your 4163236400 form online today to ensure prompt healthcare processing.