Dd Form 2526 - Case Abstract For Malpractice Claims
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41. DATE OF REPORT
2. CLAIMANT LAST NAME REPORT CONTROL SYMBOL
CASE ABSTRACT FOR
(YYYYMMDD)
DD-HA(AR)1782
MALPRACTICE CLAIMS
3. TYPE OF REPORT (X one)
4. DATES OF ACT(S) OR OMISSION(S) (YYYYMMDD)
a. BEGINNING DATE
b. ENDING DATE
a. INITIAL
b. CORRECTION OR ADDITION
c. REVISION TO ACTION
d. VOID PREVIOUS REPORT
5. DATE CLAIM FILED
6. DATE OF JUDGMENT OR
7. MEDICAL TREATMENT FACILITY
(YYYYMMDD)
SETTLEMENT
(YYYYMMDD)
a. NAME
b. DMIS CODE
8. PRACTITIONER INFORMATION
a. NAME (Last, First, Middle Initial)
b. SSN
c. DATE OF BIRTH (YYYYMMDD)
d. NAME OF PROFESSIONAL SCHOOL ATTENDED
e. DATE GRADUATED
f. SPECIALTY CODE
(YYYYMMDD)
g. STATUS (X one)
(9) Non-Personal
(1) Army
(3) Air Force
(5) Civilian GS
(7) Partnership External
Services Contract
(2) Navy
(4) PHS
(6) Partnership Internal
(8) Personal Services Contract
h. SOURCE OF ACCESSION (X all that apply)
(1) Military
(2) Civilian
(a) Volunteer
(d) National Guard
(a) Civil Service
(d) Foreign National (Local Hire)
(b) Armed Forces Health Pro-
(e) Reserve
(b) Contracted
(e) Other (Specify)
fessional Scholarship Program
(f) Other (Specify)
(c) Consultant
(c) Uniformed Services Univer-
sity of Health Sciences
i. LICENSING INFORMATION
(1) State of License
(2) License Number
(1) State of License
(2) License Number
9. TYPE OF PRACTITIONER AND SPECIALTY (FIELD OF LICENSURE) (X all that apply)
a. PHYSICIAN DEGREE
M.D. (010)
D.O. (020)
(1) Highest Level of Specialization
(a) Board Certified
(b) Residency Completed
(c) In Residency (015/025)
(d) No Residency
(2) Primary Specialty
(h) Internal Medicine (Cont.)
(l) Otorhinolaryngology
(t) Surgery, General (Cont.)
(a) In Training
(h.c) Infectious Disease
(m) Orthopedics
(t.d) Oncology
(b) General Practice (GMO)
(h.d) Nephrology
(n) Pathology
(t.e) Pediatric
(c) Anesthesiology
(h.e) Pulmonary
(o) Pediatrics
(t.f) Peripheral Vascular
(d) Aviation Medicine
(h.f) Rheumatology
(p) Physical Medicine
(t.g) Plastic
(e) Dermatology
(h.g) Tropical Medicine
(q) Preventive Medicine
(u) Underseas Medicine
(f) Emergency Medicine
(h.h) Allergy/Immunology
(r) Psychiatry
(v) Urology
(g) Family Practice
(h.i) Cardiology
(s) Radiology
(w) Intensivist
(h) Internal Medicine
(h.j) Endocrinology
(t) Surgery, General
(x) Neonatologist
(h.a) Gastroenterology
(i) Neurology
(t.a) Cardio-Thoracic
(y) Other (Specify)
(h.b) Hematology -
(j) Obstetrics/Gynecology
(t.b) Colon-Rectal
Oncology
(k) Ophthalmology
(t.c) Neurosurgery
(3) Board Certification(s)
b. DENTIST
DENTIST (030)
(1) Highest Level of Specialization
(2) Primary Specialty
(a) Board Certified
(c) In Residency (035)
(a) General Dental Officer
(c) Other (Specify)
(b) Residency Completed
(d) No Residency
(b) Oral Surgeon
(3) Board Certification(s)
c. OTHER PRACTITIONERS
OTHER PRACTITIONERS
Audiologist (400)
Nurse Anesthetist (110)
Optometrist (636)
Registered Nurse (100)
Clinical Dietician (200)
Nurse Midwife (120)
Physical Therapist (430)
Emergency Medical
Clinical Pharmacist (050)
Nurse Practitioner (130)
Physician Assistant (642)
Technician
Clinical Psychologist (370)
Occupational Therapist
Podiatrist (350)
Other (Specify)
Clinical Social Worker (300)
(410)
Speech Pathologist (450)
DD FORM 2526, FEB 2000
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