DRAFT - Exhibit E - Standard Form 513.pdf

Standard Form PDF 435 KB Posted

Attached to
Medical Referral Services MEPCOM Industry Day
Solicitation number
W81K04-24-R-0001
Issued by

About this file

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This document contains a Standard Form 513 medical record consultation sheet template. The form is to be used by medical providers to request and document medical consultations. It requests identifying information about the patient, provider, and consultation. Fields include date, reason for request, provisional diagnosis, place and type of consultation, whether records were reviewed or the patient examined, signature and date fields. The related federal contract opportunity is a special notice for an Army Medical Command industry day regarding medical referral services for the Medical Command Expeditionary Capability Command. The industry day will provide information on the command's medical referral processes and systems.

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Other versions and copies of SF 513

7 government files on GovTribe name SF 513. Different revisions are separate documents; copies of this exact file point search engines to its first posting.

File Revision Posted Attached to
Draft Revised Exhibit E - Standard Form 513.pdf Same revision and size as this file Revision not stated Medical Referral Services
DRAFT - Exhibit E - Standard Form 513.pdf Same revision and size as this file Revision not stated Medical Referral Services
SF 513.pdf Same revision and size as this file Revision not stated 6515--VISN-Wide Prescription Eyeglass and Optician Services
Exhibit_E_Standard_Form_513.pdf Same revision and size as this file Revision not stated MEPCOM Referral Services
Exhibit_E._Standard_Form_513.pdf Same revision and size as this file Revision not stated Military Entrance Processing Station (MEPS) Medical Referral Services
Exhibit_E._Standard_Form_513.pdf Same revision and size as this file Revision not stated MEPCOM Medical Referral Services

Who attaches SF 513

Agency Files
Department of the Army Medical Command 6
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 17 1

Other files

File Type Posted
Med Referral Industry Day QA.pdf PDF
Industry Day Med Referral Slides 07 August 2023.pptx PPTX presentation
INDUSTRY DAY MEDICAL REFERRAL SERVICES KTR ATTENDEES 08 AUG 2023.doc DOC document
Industry Day Question Form Medical Referrals.xlsx XLSX spreadsheet
DRAFT - Exhibit D - DD Form 1966.pdf PDF
DRAFT - Exhibit A - Locations and Radius (21 Jun).xlsx XLSX spreadsheet
DRAFT QASP MED REF JULY.docx DOCX document
DRAFT - Exhibit F -FY23 Operating Schedule.pdf PDF
Draft - Exhibit G Table 1 - Required Specialty Consultants by MEPS (13 Jul).xlsx XLSX spreadsheet
W81K04-24-R-0001 DRAFT.pdf PDF
DRAFT - Exhibit G - Required Services and Scheduling Times 13 July.pdf PDF
DRAFT - Exhibit B - Specialty Consultant Qualifications July 2023L.docx DOCX document
Exhibit C DHA PM 6025.13 Volume 4.pdf PDF
Show all 13

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AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD CONSULTATION SHEET

REQUEST

TO: FROM: (Requesting physician or activity) DATE OF REQUEST

REASON FOR REQUEST (Complaints and findings)

PROVISIONAL DIAGNOSIS

DOCTOR'S SIGNATURE APPROVED PLACE OF CONSULTATION

BEDSIDE ON CALL

ROUTINE

72 HOURS

TODAY

EMERGENCY

CONSULTATION REPORT

RECORDS REVIEWED YES NO PATIENT EXAMINED YES NO TELEMEDICINE NOYES

(Continue on reverse side)

SIGNATURE AND TITLE DATE

HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT DEPARTMENT/ SERVICE OF PATIENT

RELATION TO SPONSOR SPONSOR'S NAME (Last, first, middle) SPONSOR'S ID NUMBER (SSN or Other)

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first middle; ID no. (SSN or other); Sex; Date of Birth; Rank/Grade)

CONSULTATION SHEET

Medical Record

STANDARD FORM 513 (REV. 4-98)

Prescribed by GSA/ICMR (41 CFR) 101-11.203(b)(10)

REGISTER NO. WARD NO.

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD

CONSULTATION SHEET

REQUEST

TO:

FROM: (Requesting physician or activity)

DATE OF REQUEST

REASON FOR REQUEST (Complaints and findings)

PROVISIONAL DIAGNOSIS

DOCTOR'S SIGNATURE

APPROVED

PLACE OF CONSULTATION

BEDSIDE

ON CALL

ROUTINE

72 HOURS

TODAY

EMERGENCY

CONSULTATION REPORT

RECORDS REVIEWED

YES

NO

PATIENT EXAMINED

YES

NO

TELEMEDICINE

NO

YES

(Continue on reverse side)

SIGNATURE AND TITLE

DATE

HOSPITAL OR MEDICAL FACILITY

RECORDS MAINTAINED AT

DEPARTMENT/ SERVICE OF PATIENT

RELATION TO SPONSOR

SPONSOR'S NAME (Last, first, middle) SPONSOR'S ID NUMBER (SSN or Other) PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first middle; ID no. (SSN or other); Sex; Date of Birth; Rank/Grade)

CONSULTATION SHEET

Medical Record

STANDARD FORM 513 (REV. 4-98)

Prescribed by GSA/ICMR (41 CFR) 101-11.203(b)(10) CONSULTATION SHEET Medical Record. STANDARD FORM 513 (Rev. 4-98). Prescribed by GSA/ICMR (41 CFR) 101-11.203(b)(10).

REGISTER NO.

WARD NO.

PLACE OF CONSULTATION. BEDSIDE.: 0
PLACE OF CONSULTATION. ON CALL.: 0
ROUTINE: 0
72 HOURS: 0
EMERGENCY: 0
TODAY: 0
RECORDS REVIEWED YES: 0
RECORDS REVIEWED NO: 0
PATIENT EXAMINED YES: 0
PATIENT EXAMINED NO: 0
TELEMEDICINE YES: 0
TELEMEDICINE NO: 0
TO:
FROM (Requesting physician or activity):
DATE OF REQUEST. Enter 2 digit month, 2 digit day and 4 digit year.:
REASON FOR REQUEST (COMPLAINTS AND FINDINGS):
PROVISIONAL DIAGNOSIS:
DOCTOR'S SIGNATURE. THIS IS A PROTECTED FIELD.:
APPROVED:
SIGNATURE. THIS IS A PROTECTED FIELD.:
TITLE:
DATE. Enter 2 digit month, 2 digit day and 4 digit year.:
HOSPITAL OR MEDICAL FACILITY:
RECORDS MAINTAINED AT :
DE APARTMENT/ SERVICE OF PATIENT:
RELATION TO SPONSOR:
SPONSOR'S NAME (LAST, FIRST, MIDDLE):
SPONSOR'S ID NUMBER (SSN OR OTHER):
REGISTER NUMBER:
WARD NUMBER:
SIGNATURE. THIS IS A PROTECTED FIELD.:
CONSULTATION REPORT:
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first middle; ID number (SSN

or other); Sex; Date of Birth; Rank/Grade):

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