Fillable Printable Medical Record Privacy Act Statement
Fillable Printable Medical Record Privacy Act Statement
Medical Record Privacy Act Statement
PREVIOUS EDITION IS NOT USABLE AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information
may be provided to appropriate Government agencies when relevant to civil, criminal or regulatory investigations or prosecutions.
The Social Security Number, authorized by Public Law 93-579 Section 7 (b) and Executive Order 9397, is used as a unique
identifier to distinguish between employees with the same names and birth dates and to ensure that each individual's record in
the system is complete and accurate and the information is properly attributed.
CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
HOSPITAL OR MEDICAL FACILITY
SPONSOR'S NAME
STATUS DEPARTMENT/SERVICE
RELATIONSHIP TO SPONSOR
RECORDS MAINTAINED AT
REGISTER NUMBER WARD NUMBER
SOCIAL SECURITY/ID NUMBER
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID NUMBER or
Social Security Number; Gender; Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600
(REV. 11/2010)
Prescribed by GSA/ICMR
FIRMR (41 CFR) 201-9.202-1
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
STANDARD FORM 600
(REV. 11/2010) BACK
