Part A: identification
Item 1a has boxes for OPERATION OR PROCEDURE, ANESTHESIA, SEDATION and TRANSFUSION (check all applicable boxes), and item 1b is a DESCRIBE box.
OF522
Medical Record - Request for Administration of Anesthesia and Performance of Operations and Other Procedures
- Agency
- GSA
- Revision
- Rev. 8/2003
- Fillable fields
- 27
- Pages
- 1
- Official source
- GSA form page
- Checked
- October 20, 2026
Optional Form 522 (OF 522): Request for Administration of Anesthesia
Optional Form 522 (OF 522), Request for Administration of Anesthesia and for Performance of Operations and Other Procedures, is a one-page medical record printed as OPTIONAL FORM 522 (REV. 8/2003). Its footer says Prescribed by GSA/ICMR FMR (41 CFR) 102-194.30(i), and GSA hosts a copy in its forms library.
Part A identifies the operation or procedure, anesthesia, sedation or transfusion. Part B is a statement of request in the patient's words: what was explained, the operation or procedure in layman's language, the doctor, any exceptions, the disposal of tissues, and consent to photographs and observation. Part C holds the signatures of the counseling physician or dentist, the patient, a sponsor or guardian when needed, and witnesses.
The form says appropriate items in parts A and B must be completed before signing. You can fill it out free in your browser on this page and download the result without an account.
What's on OF 522
Part B items 2 to 4: the request
A statement that the nature, purpose, alternatives, risks and possible complications were explained and no guarantees made, the procedure in layman's language, the doctor's name, and the request for the procedure and anesthesia.
Part B items 5 and 6: exceptions and tissue
Exceptions to surgery or anesthesia, if any, and a request that the medical facility dispose of any tissues or parts that it may be necessary to remove.
Part B item 7: photographs
Consent to photographs, movies and observation by authorized personnel, on conditions that the patient's name is not used to identify the pictures and that they are used only for medical or dental study or research.
Part C: signatures
Item 8 for the counseling physician or dentist, item 9 for the patient and a witness, and item 10 for a sponsor or guardian and a witness.
Patient's identification
For typed or written entries: name (last, first, middle), ID no. (SSN or other), and hospital or medical facility, with register and ward numbers.
The page is split into Parts A, B and C, plus a patient identification block.
How to fill out OF 522
- 1
Identify what is requested
Check all applicable boxes in item 1a and describe it in item 1b.
- 2
Describe it in plain words
Item 2 asks for the operation or procedure in layman's language and the doctor who will perform or direct it.
- 3
State any exceptions
Enter exceptions to surgery or anesthesia in item 5. The form says If none, so state.
- 4
Review item 7
The form says to cross out any parts above which are not appropriate.
- 5
Sign Part C
The form says appropriate items in parts A and B must be completed before signing. The counseling physician or dentist signs item 8, and the patient or a sponsor or guardian signs with a witness.
These steps follow the form's own notes in Parts A to C.
Why fill Form OF522 on indox
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- The official blank straight from the GSA, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what the form says
Where it goes
The PDF prints no filing address. It is labeled Medical Record, and the identification block names the hospital or medical facility.
Before signing
The form says appropriate items in parts A and B must be completed before signing.
Prescribing note
The footer says Prescribed by GSA/ICMR FMR (41 CFR) 102-194.30(i).
Copies
The top of the form says AUTHORIZED FOR LOCAL REPRODUCTION.
Related forms
Who signs OF 522?
Part C of the form lists who signs and when.
Official sources and the blank
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Questions about Form OF522
Who issues OF 522?
The footer says Prescribed by GSA/ICMR FMR (41 CFR) 102-194.30(i). GSA hosts a copy in its forms library, printed as OPTIONAL FORM 522 (REV. 8/2003).
Who signs OF 522?
The counseling physician or dentist signs item 8. The patient signs item 9, or a sponsor or guardian signs item 10 when the patient is a minor or unable to give consent, each with a witness.
Can a member of the operating team be the witness?
The witness lines read Signature of Witness, excluding members of operating team.
What if there are no exceptions to surgery or anesthesia?
Item 5 says If none, so state.
What does OF 522 say about photographs?
Item 7 is consent to photographs, movies and observation, on conditions that the patient's name is not used to identify the pictures and that they are used only for medical or dental study or research. The form says to cross out any parts that are not appropriate.
Does the form promise a result?
In item 2 the patient acknowledges that no guarantees have been made concerning the results of the operation or procedure.