SF 513.pdf

Standard Form PDF 435 KB Posted

Attached to
6515--VISN-Wide Prescription Eyeglass and Optician Services
Solicitation number
36C25721R0087
Issued by

View the file

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 - Exhibit E - Standard Form 513.pdf Same revision and size as this file Revision not stated Medical Referral Services MEPCOM Industry Day
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
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
36C25721R0087 - Conformed Solicitation 0005.docx DOCX document
Revised SCHEDULE 0005.xlsx XLSX spreadsheet
36C25721R0087 0005.docx DOCX document
36C25721R0087 - Conformed Solicitation 0004.docx DOCX document
36C25721R0087 0004.docx DOCX document
VHA Directive 1193 Coronavirus Disease 2019 Vaccination Program for VHA Health Care Personnel (HCP) 02.pdf PDF
36C25721R0087 - Conformed Solicitation 0003.docx DOCX document
Revised SCHEDULE.xlsx XLSX spreadsheet
36C25721R0087 0003.docx DOCX document
36C25721R0087 0002.docx DOCX document
36C25721R0087 0001.docx DOCX document
36C25721R0087 - Conformed Solicitation 0001.docx DOCX document
Attachment 2 - Contractor Certification - Immigration and Nationality Act of 1952 (Complete and submit with proposal).docx DOCX document
36C25721R0087.docx DOCX document
Attachment 1 - Quality Assurance Surveillance Plan (QASP) (Complete and submit with proposal).docx DOCX document
SCHEDULE.xlsx XLSX spreadsheet
Show all 16

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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):

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