SF519B

Radiologic Consultation Request/Report (Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)

Agency
GSA
Revision
Rev. 8/1983
Fillable fields
72
Pages
3
Official source
GSA form page
Checked
October 20, 2026
Fill SF519B online
Page 1 of form SF519B

Standard Form 519-B (SF 519-B): Radiologic Consultation Request/Report

Standard Form 519-B (SF 519-B), Radiologic Consultation Request/Report, is a medical record for Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations, printed as STANDARD FORM 519-B (Rev. 8-83). Its footer says Prescribed by GSA/MIR FIRMR (41 CFR) 201-45.505, and GSA hosts a copy in its forms library.

The top half is the request: the examination(s) requested, the patient's age and sex, SSN (Sponsor), ward or clinic, register and film numbers, a pregnant yes or no box, the requestor's printed name, telephone or page number, signature and date, and the specific reason(s) for the request (complaints and findings). The lower half holds the dates of examination, report and transaction, the radiologic report itself, the patient's identification, the location of medical records and of the radiologic facility, and a signature.

The PDF prints the page three times, labeled 1 - Medical Record, 2 - Physician and 3 - Radiology. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Standard Form 519-B (SF 519-B): Radiologic Consultation Request/Report, as printed by GSA

What's on SF 519-B

Examination and patient details

EXAMINATION(S) REQUESTED, AGE, SEX, SSN (Sponsor), WARD/CLINIC, REGISTER NO., FILM NO. and a PREGNANT yes or no box.

Requestor block

REQUESTED BY (Print), TELEPHONE/PAGE NO., SIGNATURE OF REQUESTOR and DATE REQUESTED.

Specific reason(s) for request

A box for the complaints and findings behind the request.

Dates

DATE OF EXAMINATION, DATE OF REPORT and DATE OF TRANSACTION, each written as month, day, year.

Radiologic report

The large RADIOLOGIC REPORT area in the middle of the page.

Identification, locations and signature

PATIENT'S IDENTIFICATION (name, last, first, middle, and medical facility), LOCATION OF MEDICAL RECORDS, LOCATION OF RADIOLOGIC FACILITY and SIGNATURE.

Each copy has the same blocks, top to bottom.

How to fill out SF 519-B

  1. 1

    Name the examination

    Enter the examination(s) requested and the patient details: age, sex, SSN (Sponsor), ward or clinic, register number and film number.

  2. 2

    Mark the pregnancy box

    The PREGNANT block has YES and NO boxes.

  3. 3

    Give the reasons

    Write the specific reason(s) for the request, which the form describes as complaints and findings.

  4. 4

    Sign the request

    Print the requestor's name, add a telephone or page number, then sign and date the request.

  5. 5

    Complete the report section

    Enter the dates of examination, report and transaction as month, day, year, the radiologic report, the two locations and the signature.

These steps follow the order of the blocks on the page.

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Where it goes and what the form says

Where it goes

The PDF prints no filing address. Its three copies are labeled 1 - Medical Record, 2 - Physician and 3 - Radiology.

Prescribing note

The footer says Prescribed by GSA/MIR FIRMR (41 CFR) 201-45.505.

Stock number

The top of each copy prints NSN 7540-01-165-7294.

Instructions and privacy

The PDF prints no instructions, Privacy Act statement or burden estimate.

Related forms

Who fills out SF 519-B?

  • The requestor

    The REQUESTED BY (Print), TELEPHONE/PAGE NO., SIGNATURE OF REQUESTOR and DATE REQUESTED blocks are for the person asking for the examination, who also gives the specific reasons for the request.

  • The radiologic facility

    The lower half has the RADIOLOGIC REPORT area, the dates of examination and report, the LOCATION OF RADIOLOGIC FACILITY and a SIGNATURE line.

  • The patient, as identified

    The patient does not sign. The form records age, sex, SSN (Sponsor), pregnancy yes or no, and the patient's identification: name (last, first, middle) and medical facility.

  • Medical record, physician and radiology

    The three printed copies are labeled 1 - Medical Record, 2 - Physician and 3 - Radiology.

The form prints no instructions. Its blocks show who requests the examination, who reports on it and where the copies go.

Official sources and the blank

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Questions about Form SF519B

Who issues SF 519-B?

The footer says Prescribed by GSA/MIR FIRMR (41 CFR) 201-45.505. GSA hosts a copy in its forms library, printed as STANDARD FORM 519-B (Rev. 8-83).

Which examinations does SF 519-B cover?

Its subtitle reads Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations.

Why does the PDF have three pages?

The same page is printed three times, labeled 1 - Medical Record, 2 - Physician and 3 - Radiology.

Does SF 519-B ask about pregnancy?

Yes. The PREGNANT block next to the film number has YES and NO boxes.

How are dates written on SF 519-B?

The date of examination, date of report and date of transaction boxes each say Month, day, year.