Draft Revised Exhibit E - Standard Form 513.pdf
PDF 435 KB Posted
- Attached to
- Medical Referral Services
- Solicitation number
- W81K04-23-R-MREF
- Issued by
-
Department of the Army Medical Command
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| DRAFT REVISED - Exhibit A - Locations and Radius (24 Feb).xlsx | XLSX spreadsheet | |
| Exhibit D - DD Form 1966 (002).pdf | ||
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| Industry Comment Resolution Matrix.xlsx | XLSX spreadsheet | |
| DRAFT - Exhibit E - Standard Form 513.pdf | ||
| DRAFT - Exhibit D - DD Form 1966.pdf | ||
| DRAFT PWS MED REFERRAL.docx | DOCX document | |
| DRAFT - Exhibit A Locations.xlsx | XLSX spreadsheet | |
| DRAFT - Exhibit G.docx | DOCX document | |
| DRAFT - Exhibit F -FY23 Operating Schedule.pdf |
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Text version
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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