TELEPHONE REPORTING FORMAT
PATIENT'S NAME: Last, first, and middle initial. State if a junior, a II, III, etc.
AUTHORIZATION NUMBER: Self-explanatory.
SOCIAL SECURITY NUMBER: Use individual's SSN or the sponsor's if the patient is a dependent.
STATUS: Service affiliation or relationship to sponsor, i.e., USA/active duty: USMC, Retired/TDRL;
dependent daughter, USN/active duty; or dependent wife, USAF; Retired/ Deceased; etc.
Required for active duty only. Member's pay grade, i.e., E-4, 0-4, etc.
PRECEDENCE: Report patients as URGENT, PRIORITY, or ROUTINE as defined in AFR 164-
5/AR 40-535/OPNAVINST 4630.9C.
CLASS: Report patients as XA , XB, XX, etc., as defined in MAC Regulation 164-5.
AGE: State in years. If less than two years , then in months and if newborn, in days.
Report male or female.
WEIGHT: Self-explanatory. State in pounds.
REPORTED BY: Provide the name of the patient evacuation clerk who is reporting the patient.
TELEPHONE: Provide the telephone number of the reporting MTF. The telephone number must be
one which is readily available to receive incoming telephone calls.
13. MEDICAL SPECIALTY: Clinical specialty requirements(s), i.e., SOP, SOR, SNS, etc.
State the primary specialty fi rst if more than one is required.
See item 13 above.
MEDICAL SPECIALTY: See item 13 above.
DIAGNOSIS: Use diagnosis codes contained in the International Classification of Diseases , ninth
revision, 1975 (ICD9). State primary ICD number first followed by others as appropriate. Also give
nomenclature of diagnosis.
Table 3-2. Telephone reporting format (continued).