Standard Form 513 (SF 513): Consultation Sheet

Request: who and when

TO, FROM (Requesting physician or activity) and DATE OF REQUEST.

Reason and provisional diagnosis

REASON FOR REQUEST (Complaints and findings) and PROVISIONAL DIAGNOSIS, each with an open area.

Signature, approval and place

DOCTOR'S SIGNATURE, APPROVED, PLACE OF CONSULTATION with BEDSIDE and ON CALL boxes, and boxes for ROUTINE, TODAY, 72 HOURS and EMERGENCY.

Consultation report

Yes or no boxes for RECORDS REVIEWED, PATIENT EXAMINED and TELEMEDICINE, then a large report area marked Continue on reverse side, and SIGNATURE AND TITLE with DATE.

Identification blocks

Hospital or medical facility, records maintained at, department or service of patient, relation to sponsor, sponsor's name and ID number (SSN or Other), patient's identification, register number and ward number.

The single page has a request section, a report section and identification blocks.

1. 1

   Identify the patient

   For typed or written entries, the form asks for the patient's name (last, first, middle), ID no. (SSN or other), sex, date of birth and rank or grade, plus register and ward numbers.

2. 2

   Address the request

   Enter who the request goes to, the requesting physician or activity, and the date of request.

3. 3

   Describe the reason

   Write the complaints and findings behind the request and the provisional diagnosis.

4. 4

   Choose the place and timing boxes

   Check bedside or on call and one of routine, today, 72 hours or emergency. The doctor signs, and the APPROVED box is filled in.

5. 5

   Write and sign the report

   Check yes or no for records reviewed, patient examined and telemedicine, write the report, continuing on the reverse side if needed, then sign with title and date.

The form prints no step-by-step instructions. These steps follow its blocks.

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• The requesting physician or activity

  The FROM box reads Requesting physician or activity. The request area ends with a DOCTOR'S SIGNATURE line.

• The approver

  Next to the doctor's signature is a box marked APPROVED. The form does not say who approves.

• The person writing the report

  The consultation report closes with a SIGNATURE AND TITLE line and a DATE box.

• The patient and sponsor

  The patient is identified by name, ID no. (SSN or other), sex, date of birth and rank or grade. The form also asks for the relation to sponsor, the sponsor's name and the sponsor's ID number.

• The hospital or medical facility

  The bottom rows name the hospital or medical facility, where records are maintained, the department or service of the patient, and the register and ward numbers.

The form prints signature lines for the request and for the report, and identification blocks for the patient and the facility. It does not say who fills in each block.

• Official GSA form page

  The agency’s own page for Form SF513.

• Blank PDF

  The official blank form, to print or fill by hand.

  Download blank PDF

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