Exhibit_E_Standard_Form_513.pdf

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Attached to
MEPCOM Referral Services Federal contract opportunity
Solicitation number
W81K04-18-R-0006
Issued by
Department of the Army Medical Command

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Exhibit E-Standard Form 513

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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):

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