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NYS DOH Epidote Expanded Access for Treatment Resistant Epilepsy Study Referral Form GENERAL PATIENT INFORMATION Date of Request: / / DOB: / / Age: Gender: Male Female Patient S.S. # (Last 4 digits):

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How to fill out nysdoh study referral form

How to fill out nysdoh study referral form:

01

Start by gathering all the necessary information: Make sure you have all the relevant details before filling out the form. This may include personal information, medical history, and contact information of the referring healthcare professional.

02

Read the instructions carefully: Take your time to carefully read through the instructions provided on the form. This will ensure that you understand all the requirements and provide accurate information.

03

Fill in personal details: Begin by filling in your personal details such as your name, address, date of birth, and contact information. Double-check for any errors or missing information.

04

Provide medical information: The form may require you to provide details about your medical condition, current medications, and any previous treatments you have received. Be sure to fill in this information accurately and to the best of your knowledge.

05

Include the referring healthcare professional's information: Fill in the details of the healthcare professional who is referring you for the study. This includes their name, contact information, and any specific instructions or notes they have provided.

06

Submit the form: Once you have completed filling out the form, review it thoroughly to ensure accuracy. Check for any missing information or mistakes. Once you are confident that everything is filled in correctly, sign and date the form before submitting it as instructed.

Who needs nysdoh study referral form?

01

Individuals interested in participating in a study: The nysdoh study referral form is required for individuals who are interested in participating in a study conducted by the New York State Department of Health (NYSDOH). This form helps collect important information about the individuals and their medical history, ensuring that the study is conducted accurately and effectively.

02

Healthcare professionals: Healthcare professionals who wish to refer their patients to participate in a study conducted by NYSDOH will also need to complete the nysdoh study referral form. This helps in documenting the referral and providing necessary information about the patients being referred.

03

Researchers and coordinators: Researchers and study coordinators within NYSDOH will use the nysdoh study referral form as a means to gather information about potential study participants. This form allows them to screen individuals and determine if they meet the eligibility criteria for the study.

Remember, it is essential to carefully follow the instructions while filling out the nysdoh study referral form and provide accurate and complete information to ensure a smooth process for both the participants and the researchers.

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What is nysdoh study referral form?

The nysdoh study referral form is a document used to refer a study to the New York State Department of Health (NYSDOH) for review and approval.

Who is required to file nysdoh study referral form?

Researchers and institutions conducting studies in New York State are required to file the nysdoh study referral form.

How to fill out nysdoh study referral form?

The nysdoh study referral form can be filled out online on the NYSDOH website or submitted via mail with the required information.

What is the purpose of nysdoh study referral form?

The purpose of the nysdoh study referral form is to ensure that studies conducted in New York State comply with state regulations and ethical standards.

What information must be reported on nysdoh study referral form?

The nysdoh study referral form requires information on the study protocol, investigators, funding sources, and potential risks to participants.

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