SF600-18.pdf

558 KB Posted

Attached to
Medical Surveillance
Solicitation number
FA670325Q0006
Issued by

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The document is a Standard Form 600 (SF-600) Medical Record, a blank chronological record of medical care form designed for tracking patient medical information. The form includes fields for patient identification, hospital or medical facility details, and a chronological record of medical symptoms, diagnoses, treatments, and treating organizations. The form contains a Privacy Act Statement noting that the information is subject to the Privacy Act of 1974 and may be provided to government agencies for civil, criminal, or regulatory investigations. The form is marked "FOR OFFICIAL USE ONLY" and is prescribed by GSA/ICMR with a revision date of 8/2018.

The form is blank and contains no filled-in medical information. It provides space for detailed medical entries, including date, symptoms, diagnosis, treatment, and treating organization, with an instruction to sign each entry. Additional fields include sections for hospital information, patient status, department/service, sponsor details, and patient identification information such as name, ID number, social security number, gender, date of birth, and rank/grade.

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FOR OFFICIAL USE ONLY

When Filled OutPREVIOUS EDITION IS NOT USABLE AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD

PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal or regulatory investigations or prosecutions.

The Social Security Number, authorized by Public Law 93-579 Section 7 (b) and Executive Order 9397, is used as a unique identifier to distinguish between employees with the same names and birth dates and to ensure that each individual's record in the system is complete and accurate and the information is properly attributed.

CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

HOSPITAL OR MEDICAL FACILITY

SPONSOR'S NAME

STATUS DEPARTMENT/SERVICE

RELATIONSHIP TO SPONSOR

RECORDS MAINTAINED AT

REGISTER NUMBER WARD NUMBER

SOCIAL SECURITY/ID NUMBER

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID NUMBER or Social Security Number; Gender; Date of Birth; Rank/Grade.)

CHRONOLOGICAL RECORD OF MEDICAL CARE

Medical Record

STANDARD FORM 600 (REV. 8/2018)

Prescribed by GSA/ICMR

FIRMR (41 CFR) 201-9.202-1

When Filled Out

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

STANDARD FORM 600 (REV. 8/2018) BACK

When Filled Out

PREVIOUS EDITION IS NOT USABLE

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD

PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal or regulatory investigations or prosecutions. The Social Security Number, authorized by Public Law 93-579 Section 7 (b) and Executive Order 9397, is used as a unique identifier to distinguish between employees with the same names and birth dates and to ensure that each individual's record in the system is complete and accurate and the information is properly attributed.

CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

HOSPITAL OR MEDICAL FACILITY

SPONSOR'S NAME

STATUS

DEPARTMENT/SERVICE

RELATIONSHIP TO SPONSOR

RECORDS MAINTAINED AT

REGISTER NUMBER

WARD NUMBER

SOCIAL SECURITY/ID NUMBER

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID NUMBER orSocial Security Number; Gender; Date of Birth; Rank/Grade.)

CHRONOLOGICAL RECORD OF MEDICAL CARE

Medical Record

STANDARD FORM 600 (REV. 8/2018)

Prescribed by GSA/ICMR

FIRMR (41 CFR) 201-9.202-1

DATE

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

STANDARD FORM 600 (REV. 8/2018) BACK

Date. Line 13 of 28. Enter 2 digit month, 2 digit day and 4 digit year.:
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION. Sign each entry:
HOSPITAL OR MEDICAL FACILITY:
STATUS:
DEPARTMENT/SERVICE:
RELATIONSHIP TO SPONSOR:
REGISTER NUMBER:
WARD NUMBER:
RECORDS MAINTAINED AT:
SPONSOR'S NAME:
PATIENT'S IDENTIFICATION. For typed or written entries, give: Name - last, first, middle, ID Number or Social Security Number, Sex, Date of Birth, Rank/Grade.:
SOCIAL SECURITY NUMBER/ID NUMBER:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:
Digital Signature.:

File details come from the government source that posted it. Updated .