17.
ORIGINATING MTF: Give name of MTF, i.e., NRMC Jacksonville, FL; OMA Charleston; or Walter
Reed AMC.
18.
ORIGINATING CIVILIAN MTF: Give name and full address.
Provide telephone number of that
treatment facility's best contact point for the case involved.
19.
DESTINATION MTF: Report as indicated in item #18.
20.
DESTINATION CIVILIAN MTF: Give name and full address.
Provide telephone number of that
treatment facility's best contact point for the case involved.
21.
VA CODE:
Defense Patient Evacuation Office (DPEO) use only.
22.
STATION CODE (ORIGINATING): DPEO and PAC use only.
23.
STATION CODE (DESTINATION): DPEO and PAC use only.
24.
ATTENDING PHYSICIAN/TELEPHONE:
Provide the name and telephone number of the patient's
attending physician.
25.
WARD NUMBER/TELEPHONE : Report ward/telephone numbers where the patient is being treated.
26.
ACCEPTING PHYSICIAN:
Provide name of accepting physician at destination MTF when required
or otherwise arranged.
27.
APPROVAL AUTHORITY:
Give the name of the appropriate approving official for those cases
requiring special approval.
28.
REASON REGULATED:
DPEO use only.
29.
DATE OF LAST VISIT: Provide the date of the most recent hospitalization on all follow-up cases.
30.
TYPE BAG: Report as suitcase, duffle bag, foot locker, hanging bag, other, or no bag.
31.
BAG TAG: All patients and attendants must have bags labeled in accordance with AFR 164-3/AR
40-40/BUMEDINST 4650.2A. Provide tag number(s) as required by reference.
32.
BAG WEIGHT: Self-explanatory.
33.
ADMIN/OVERSEAS: DPEO use only.
34.
MODE: Report mode of patient travel, i.e., air evacuation, train, helicopter, bus, ground ambulance,
etc.
35.
SUPPLEMENTAL: Report additional information as required for patient transfer.
TABLE 3-2 Telephone Reporting Format (continued)
MD0752
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