Diagnosis and date
The first row has DIAGNOSIS and DATE.
SF526
Medical Record - Interstitial/Intercavitary Therapy
- Agency
- GSA
- Revision
- Rev. 2/1995
- Fillable fields
- 72
- Pages
- 2
- Official source
- GSA form page
- Checked
- October 20, 2026
Standard Form 526 (SF 526): Interstitial/Intercavitary Therapy
Standard Form 526 (SF 526), Interstitial/Intercavitary Therapy, is a two-page medical record printed as STANDARD FORM 526 (REV. 2-95). Its footer says Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1, and GSA hosts a copy in its forms library.
The front records the diagnosis and date, the isotope, the total quantity in MG/mCi, the applicator, the total time in HRS., a large diagram area and a dose information area, followed by the physician's signature, date, identification number and organization, and the patient's identification. The back is a ruled table with a DATE column and a RECORD OF TREATMENTS column.
The PDF prints no instructions. You can fill it out free in your browser on this page and download the result without an account.
What's on SF 526
Isotope and total quantity
ISOTOPE, and TOTAL QUANTITY with the unit MG/mCi printed in the box.
Applicator and total time
APPLICATOR, and TOTAL TIME with the unit HRS. printed in the box.
Diagram and dose information
A large DIAGRAM area and a DOSE INFORMATION area fill most of the front.
Signature and identification
Signature of physician, date, identification number, organization, the patient's identification, and register and ward numbers.
Back: record of treatments
A ruled table with a DATE column and a RECORD OF TREATMENTS column, marked STANDARD FORM 526 (REV. 2-95) BACK.
How to fill out SF 526
- 1
Enter the diagnosis
Fill in the diagnosis and the date in the top row.
- 2
Record the source and timing
Enter the isotope, the total quantity in MG/mCi, the applicator and the total time in HRS.
- 3
Add the diagram and dose
Use the DIAGRAM area and enter the DOSE INFORMATION below it.
- 4
Sign and identify
The physician signs and adds the date, identification number and organization. Then complete the patient's identification with register and ward numbers.
- 5
Log treatments on the back
Enter each treatment with its date in the RECORD OF TREATMENTS table.
These steps follow the order of the blocks on the two pages.
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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.
Prescribing note
The footer says Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1.
Copies
The top of the form says AUTHORIZED FOR LOCAL REPRODUCTION.
Instructions and privacy
The PDF prints no instructions, Privacy Act statement or burden estimate.
Related forms
Who fills out SF 526?
The form prints no instructions. Its blocks show who signs and whose record it is.
Official sources and the blank
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Questions about Form SF526
Who issues SF 526?
The footer says Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1. GSA hosts a copy in its forms library, printed as STANDARD FORM 526 (REV. 2-95).
What units does SF 526 use?
The total quantity box prints MG/mCi and the total time box prints HRS.
What goes on the back of SF 526?
A ruled table with a DATE column and a RECORD OF TREATMENTS column.
Who signs SF 526?
The front has one signature box, SIGNATURE OF PHYSICIAN, with the date, identification number and organization beside it.
Does SF 526 come with instructions?
No. The PDF prints only the form's labeled blocks on the front and the treatment table on the back.