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Referral for Deactivation of Implanted Cardioverter Defibrillator (ICD)
Client/Patient Contact Information
Name: ___
Address: ___
Phone Number: ___
Patients current location:Acute Care hospital Acute
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How to fill out request-or-referral-for-icd-deactivation
How to fill out request-or-referral-for-icd-deactivation
01
Obtain the necessary form for request or referral for ICD deactivation from your healthcare provider.
02
Fill out the form accurately with your personal information, medical history, and reason for requesting ICD deactivation.
03
Make sure to sign and date the form before submitting it to your healthcare provider.
04
Follow any additional instructions provided by your healthcare provider for submitting the request or referral.
Who needs request-or-referral-for-icd-deactivation?
01
Patients with implantable cardioverter-defibrillators (ICDs) who no longer require or wish to deactivate their device.
02
Patients with ICDs who are experiencing complications or issues with their device and require deactivation for medical reasons.
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What is request-or-referral-for-icd-deactivation?
This form is used to request or refer a patient for the deactivation of an Implantable Cardioverter Defibrillator (ICD).
Who is required to file request-or-referral-for-icd-deactivation?
Healthcare providers, such as physicians or cardiologists, are required to file the request or referral for ICD deactivation.
How to fill out request-or-referral-for-icd-deactivation?
The form must be filled out with the patient's information, medical history, reason for deactivation, and signed by the healthcare provider.
What is the purpose of request-or-referral-for-icd-deactivation?
The purpose of this form is to facilitate the deactivation of an ICD for a patient based on medical necessity or patient preference.
What information must be reported on request-or-referral-for-icd-deactivation?
The form should include the patient's name, date of birth, medical record number, reason for deactivation, and any relevant medical history.
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