36C25519Q0762-006.doc
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- CRNA Locums Contract 36C25519Q0762
- Solicitation number
- 36C25519Q0762
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36C25519Q0762 S02 Consultant and Attending Visit Record Form.doc
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Text version
Department of Veterans Affairs
CONSULTANT AND ATTENDING VISIT RECORD
1. Station
Number
| 2. Identification |
| 3. Name Code |
| 4. Name |
| 5. Julian Day of Last Day of Month |
| 6. Transaction Type |
| 7. |
| 8. Service |
9. Visits
| Date |
| Time |
| Initials |
| Date |
| Time |
| Initials |
| Date |
| Time |
| Initials |
| Date |
| Time |
| Initials |
| Date |
| Time |
| Initials |
| 1 |
| In |
| 7 |
| In |
| 13 |
| In |
| 19 |
| In |
| 25 |
| In |
Out
Out
Out
Out
Out
| 2 |
| In |
| 8 |
| In |
| 14 |
| In |
| 20 |
| In |
| 26 |
| In |
Out
Out
Out
Out
Out
| 3 |
| In |
| 9 |
| In |
| 15 |
| In |
| 21 |
| In |
| 27 |
| In |
Out
Out
Out
Out
Out
| 4 |
| In |
| 10 |
| In |
| 16 |
| In |
| 22 |
| In |
| 28 |
| In |
Out
Out
Out
Out
Out
| 5 |
| In |
| 11 |
| In |
| 17 |
| In |
| 23 |
| In |
| 29 |
| In |
Out
Out
Out
Out
Out
| 6 |
| In |
| 12 |
| In |
| 18 |
| In |
| 24 |
| In |
| 30 |
| In |
Out
Out
Out
Out
Out
| Consultant/Attending named above performed services on dates indicated and claims payment at approved rate for authorized visits. |
| 31 |
| In |
Out
| 10. |
| Amount Due |
| 11. Appropriation |
| 12. Number of Visits |
For pay
Non Pay
14. Payment
Payment of this claim will not cause payee to exceed maximum amount allowed. Services were ordered, furnished, and are acceptable. Payment is approved except as noted below.
| 15. Signature |
| 16. Title |
| 17. Date |
| 18. Voucher Auditor |
| 19. Date |
19. Reference
| Name: |
| Identification: |
| Service: |
| Name: |
VAF 10-248
AUG 1983
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