In the following example, blocks 1 through 6 are__________
____________ on the A&C Form.
12. An entry in the following example would be the first
_________ on the patient's Inpatient Treatment Cover Sheet (DA Form 3647).
1. REGISTER NUMBER
13. The MTF code for Brooke AMC, Fort Sam Houston, TX is ___________.
14. The original A&C Form is filed in the patient's ___________
15. One legible copy of the A&C Form and a copy of the Inpatient Treatment Record
Cover are forwarded to _________________
______________________________for input into the IPDS data base.
16. Information from DD Form 1380, U.S. Field Medical Card (FMC) is encoded on DA
Form 2985 (A&C Form) only when the FMC reflects a__________________________
or when it represents ___________________________________________________.
17. The Automated Quality of Care Evaluation Support System (AQCESS) or the
Composite Health Care System (CHCS) Individual Patient Data System (IPDS) record
transmittals must be submitted ________ each month.