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Click ‘Get Form’ to open the planilla alta complejidad ioma in the editor.
Begin by entering the 'Fecha' (Date) at the top of the form. This is essential for record-keeping.
Fill in the 'DATOS DEL PACIENTE' section, including fields for 'Apellido' (Last Name), 'Nombres' (First Names), 'Afiliado N°' (Member Number), 'Edad' (Age), and 'Sexo' (Gender). Ensure accuracy as this information is crucial.
Next, complete the 'DATOS DEL PROFESIONAL SOLICITANTE' section with your details, including your last name, first names, and professional registration number ('Matrícula Prov.').
In the 'Diagnóstico presuntivo o confirmado' field, provide a brief description of the patient's diagnosis.
For the 'PRÁCTICAS SOLICITADAS', list each requested practice along with its code and description. If necessary, continue on the back of the form.
Finally, ensure you sign and stamp where indicated to validate your submission. Remember that all data provided is considered a sworn declaration.

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