Get the free DD Form 2164, X-Ray Verification/Certification Worksheet, November 1978 - dtic
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X-RAY VERIFICATION/CERTIFICATION WORKSHEET (Use additional sheet for remarks. Identify item by number.) LOCATION (Include Building and Room Number) I. ACTION NOT REQUIRED To be TAKEN DATE NEXT SERVICE
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How to fill out dd form 2164 x-ray
How to fill out DD Form 2164 X-Ray?
01
Start by entering the patient's personal information in the respective fields. This includes their name, rank, Social Security Number (SSN), and service branch.
02
Next, indicate the purpose of the x-ray by selecting the appropriate option. This could be for medical diagnosis, pre-employment, reemployment, retirement, or other specified reasons.
03
Provide details about the patient's condition or complaint that necessitates the x-ray. Include relevant information such as symptoms, duration, and any previous medical history that may be helpful for the evaluating physician.
04
Specify if the x-ray is part of a series or if it is a single examination.
05
Choose the type of x-ray required from the provided options. This may include routine, special, or a specific examination based on the area of the body or suspected condition.
06
Indicate any additional procedures or services requested, such as a radiologist's interpretation or a special technique to be used during the examination.
07
Sign and date the form, certifying that the information provided is accurate and complete.
08
If applicable, have the form reviewed and signed by the responsible medical officer or an authorized representative.
Who needs DD Form 2164 X-Ray?
01
Military personnel: This form is primarily used by military personnel to document and request X-ray examinations. It is mandatory for military members who require an X-ray for various reasons, including medical diagnosis, pre-employment screening, and retirement evaluations.
02
Department of Defense (DoD) employees: Apart from military personnel, DoD civilian employees may also need to fill out DD Form 2164 for X-ray examinations, depending on their job requirements or medical assessments.
03
Dependents of military personnel: In certain cases, dependents of military personnel, such as family members, may require X-ray examinations. They would typically need to complete DD Form 2164 as well to document and request these procedures.
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