fd-950.pdf

FD-950 (Rev. 5-16-2008) 67 Number:

FBI LEGAT Dependent Exam 11 years of age or younger

TO: _________________________________________________________________

FROM: FBI HQ Medical Program Contact:

Examinee: _____________________________ D.O.B. _______________

Employee’s Name: ____________________________ Employee’s Job Position: ________________________

Relation to Employee: G Self G Spouse G Dependent 12 or >

Post Assignment:

Bring all bring shot records (CDC –731, International Certificate of Vaccination).

Appointment Date: ______________ Time: _____________Type of Exam: _________________________

CPT Codes Required Core Components 99382 or 99383 Required History, PE, document race Required Height, weight, pulse Required Blood pressure (if 0ver 5 years of age) 99172 According to age Distant vision (ages 5 & >) corrected & uncorrected DS 1622 Required PE to include items # 1-15 on this form 81001 Required Urinalysis (if potty trained-sp gr, lab, sugar, WBC, RBC, casts) 83655 According to age Blood lead (ages 9 mo to 6 yrs) 85014 Required Hematocrit 86580 Required Mantoux TB test, including those with previous BCG Required Written summary of findings 86900, 01 Required Blood group & type CPT Codes Requested Supplemental Components 82955 G G6Pd G Head circumference (18 mos & <) 85660 G Sickle cell trait – black or Mediterranean descent 87177 G Stools for ova & parasite CPT Code Requested Vaccinations as indicated per assigned country 90713 G Polio Vaccine (IPV) 90707 G Measles, Mumps, Rubella (MMR) 90702 or 90718 G Tetanus/diphtheria 90690 or 90691 G Typhoid (oral or injectable) 90633 G Hepatitis A 90744 G Hepatitis B 90636 G Twinvax 90471 G Administration of FBI supplied vaccines 90657 or 90658 G Influenza 90733 or 90734 G Meningococcal 90717 G Yellow fever 90675 G Rabies, pre-exposure 90700 G DTaP, diphtheria/tetanus/pertussis 4120F G Malaria prescription