Patient'S Information Form

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PATIENT'S INFORMATION
1. I am aware that I have medical conditions to be evaluated. I can:
2. My DEERS information has been updated
a. Stay attached to the MEDHOLD unit.
YES
b. Decline MEDHOLD and request LOD for continued medical care at home of record.
NO
3. The conditions that I am being evaluated for are:
a.
b.
c.
4. The provider that I have been assigned to for coordination of my medical care:
4a. Medical Provider Name
4b. Telephone Number
4c. E-Mail Address
5. My care is scheduled for:
5a. MTF POC
5c. Other POC
5b. TRICARE Network POC
6. Medical Evaluation Board POC (If scheduled)
7. Physical Evaluation Board POC (If scheduled)
8. At the Board I can be found:
a. PEB (FIT) - Fit and be separated from active duty.
b. PEB (SEV) - Found unfit and be separated with a severance package.
c. PEB (PRDL) - Found unfit and be separated with transfer to the permanent retirement list.
d. PEB (TDRL) - Found unfit and be separated with transfer to the temporary disability list.
9. If my family members need medical care while supporting me at the MEDHOLD site they may contact:
9a. Family Member Medical Care POC
9b. Timeframe for their eligibility is:
10. If I have pay issues while attached to the MEDHOLD site my POC is:
10a. Pay Issue POC Name
10b. Telephone Number
10c. E-Mail Address
11. The VA has training programs available. The VA POC is:
11a. VA Training POC Name
11b. Telephone Number
11c. E-Mail Address
12. I have been found:
a. Fit for Duty
b. Unfit for Duty
13. I have a chronic condition that can be supported by the VA system.
13a. My records will be transferred to the VA system as of:
13b. Telephone Number
13c. E-Mail Address
14. My POC for follow-on appointments is:
14a. Follow-on appointments POC Name
14b. Telephone Number
14c. E-Mail Address
15. CM
15c. Signature
15d. Date
15a. CM Name
14b. Telephone Number
16. Patient or POC
16a. Signature
15b. Date
NAVMED 6300/15 (07-2008)
Keep this form in an accessible location for easy reference. (i.e., Post on Refrigerator)

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