fd-949.pdf

FD-949 (Rev. 5-16- 2008) 67 Number:

FBI LEGAT Multi-Use Form

TO:

FROM: FBI LEGAT Medical Program HQ Contact:

Examinee: ______________________________ D.O.B. _____________ Relation to Employee: G Self G Spouse G Dependent 12 or > Employee’s Name: _____________________________ Employee’s Job Position: _________________________________ Post Assignment:

Appointment Date: ______________ Time: _____________Type of Exam:

If Legat Special Agent also use FD-943 – Periodic Exam Bring all shot records (CDC-731, International Certificate of Vaccination). If female, bring PAP results (within the last 6 months).

CPT Codes Required Core Components 80061 Required Lipid panel 80053 Required Metabolic panels 81001 Required Urinalysis with mirco 85025 Required Complete blood count with differential 82270 Required Stool for occult blood – times 3 82947 Required Fasting blood glucose 84460, 82977 Required ALT, GGT 82955 Required G6PD (may omit if already on record) 82565 Required Creatinine 87390,91 Required HIV I and HIV II by Elisa method DS 1843 Required Physical exam needs to include items # 1-18 on this form 71020 Required Chest X-ray P/A & lateral 86580 Required Mantoux TB test, including those with previous BCG 86708 Required Hep A antibody 93000 Required Resting EKG 12 leads w/interpretation 87340 Required Hep B surface antigen 86706 Required Hep B surface antibody 86803 Required Hep C antibody 99384, 85, 86, 87 Required History, PE, document race, vital (ht, wt, B/P, pulse) 86592 Required RPR 88141 Females If PAP >6 mos offer complete GYN exam CPT Codes Requested Supplemental Components 94010 G Pulmonary function test 84153 G Prostate specific antigen 86900, 01 G Blood group & type 87177 G Stools for ova & parasite 99401, 02, 03, 04 G HIV counseling (if results are +) 83036 G Hemoglobin A1c – required on all diabetics 45330 G Sigmoidoscopy 45378 G Colonoscopy, age 50 and > or when indicated by risk factors 77057 G Mammogram with interpretation 82955 G G6PD if not on record CPT Code Per Instruction Vaccinations as indicated per assigned country 90713 G Polio Vaccine (IPV) 90707 G Measles, Mumps, rubella (MMR) 90718 G Tetanus/diphtheria 90690, 91 G Typhoid (oral or injectable) 90632 G Hepatitis A 90746 G Hepatitis B 90636 G Twinvax 90471 G Administration of FBI supplied vaccines 90658 G Influenza 90733 or 90734 G Meningococcal 90717 G Yellow fever 90675 G Rabies, pre-exposure 4120F G Malaria prescription 90581 G Anthrax, as appropriate, when available 90749 G Smallpox, as appropriate, when available 90715 G Tdap, tetanus/diphtheria/pertussis