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FD-949 (Rev12/31/2010)
DOS FORM FOR OVERSEAS DUTY
TO:
FROM: FBI Medical Program HQ Contact:
Examinee: ______________________________ DOB: _____________ 67 Number:
G Self G Spouse G Dependent 12 or > G Dependent 11 or < G Domestic Partner Examinee’s Job Position: _________________________________ Post Assignment:
Appointment Date: ______________ Time: _____________ Type of Exam: Pre-Post Exam
Bring all shot records (CDC-731, International Certificate of Vaccination).
| CPT Codes |
| Required |
| Core Components |
| 85025 |
| Required |
| Complete blood count with differential – All Ages |
| 82947 |
| Required |
| Fasting blood glucose ages 12 and older |
| 84460 |
| Required |
| ALT ages 12 and older |
| 82565 |
| Required |
| Creatinine ages 12 and older |
| 87390,91 |
| Required |
| HIV I and HIV II by Elisa method ages 12 and older |
| CPT Codes |
| Required |
| Core Tests |
| 86580 |
| Required |
| Mantoux TB test, including those with previous BCG, required for all ages unless history of previous positive |
| 93000 |
| G |
| Resting EKG 12 leads w/interpretation AGE 50 and older, or if clinically indicated. |
| DS-6561 |
| Required |
| Physician comments for positive responses to questions #1 – 25 plus additional un-numbered questions on page 2 of exam form |
| DS-6561 |
| Required |
| Physical exam needs to include items # 1-15 on this form |
| 99385, 86, 87 |
| Required |
| History, PE, (ht, wt, B/P, pulse and temperature) |
| CPT Codes |
| Requested |
| Supplemental Components |
| 86900, 86901 |
| G |
| Blood group & type |
| 99401, 02, 03, 04 |
| G |
| HIV counseling (if results are +) |
| 99401 |
| G |
| Travel counseling |
| 83036 |
| G |
| Hemoglobin A1c – required on all diabetics |
| 71020 |
| G |
| Chest X-ray P/A & Lateral if hx of previously positive, new PPD converters or if clinically indicated. |
| 94010 |
| G |
| Pulmonary Function Test – at the direction of HCPU ONLY |
| 84153 |
| G |
| Prostate Specific Antigen Male>40 - at the direction of HCPU ONLY |
| 45378 |
| G |
| Colonoscopy – at the direction of HCPU ONLY |
| 77057 |
| G |
| Mammogram – at the direction of HCPU ONLY |
| 88141 |
| G |
| PAP Smear/Complete GYN Exam – at the direction of HCPU ONLY |
| 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 OR |
| 90715 |
| G |
| Tdap, tetanus/diphtheria/pertussis |
| 90690, 91 |
| G |
| Typhoid (oral or injectable) |
| 90733 or 90734 |
| G |
| Meningococcal |
| 90675 |
| G |
| Rabies, pre-exposure |
| 4120F |
| G |
| Prescriptions: antibiotics for traveler’s diarrhea, anti-malarials, sleep aids |
| 90581 |
| G |
| Anthrax, as appropriate, when available FBI supplies |
| 90749 |
| G |
| Smallpox, as appropriate, when available |
