Fillable Dd Form 2526 - Case Abstract For Malpractice Claims (Page 2 of 4) in pdf

Dd Form 2526 - Case Abstract For Malpractice Claims Page 2

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10. PATIENT DEMOGRAPHICS

a. NAME (Last, First, Middle Initial)

c. AGE

b. SEX (X one)

(1) Male

(2) Female

(3) Unknown

e. SSN OF SPONSOR

d. STATUS (X and complete as applicable)

(1) Dependent of Active Duty

(3) Retired Member

(5) Active Duty

(2) Dependent of Retired Member

(4) Civilian Emergency

(6) Other (Specify)

11. DIAGNOSES

ICD9-CM CODE

12. PROCEDURES

ICD9-CM CODE

a. (Primary)

a. (Principal)

13. PATIENT ALLEGATION(S) OF NEGLIGENT CARE

a. DESCRIPTION OF THE ACTS OR OMISSIONS AND INJURIES UPON WHICH THE ACTION OR CLAIM WAS BASED (Limit to 300

characters.)

b. ACT OR OMISSION CODE(S) (Refer to table on Page 4)

c. CLINICAL SERVICE CODE

(1) Primary Act or Omission Code

(2) Additional Act or Omission Code

(1) Primary

(3) Additional Act or Omission Code

(4) Additional Act or Omission Code

(2) Secondary

(5) Additional Act or Omission Code

(6) Additional Act or Omission Code

(3) Tertiary

d. DESCRIPTION OF FINDINGS ON WHICH THE ACTION OR CLAIM WAS PAID

14. MALPRACTICE CLAIM MANAGEMENT

a. AMOUNT CLAIMED

b. ADJUDICATIVE BODY CASE NUMBER

c. ADJUDICATIVE

d. DATE OF PAYMENT

BODY NAME

(YYYYMMDD)

e. OUTCOME (X one)

(3) Denied: Statute of Limitations

(6) Litigated: Decision for Plaintiff

(1) Administratively Settled (Service)

(4) Denied: FERES

(7) Litigated: Decision for U.S.

(2) Denied: Dismissed by Plaintiff or

(5) Denied: Not a Legitimate Claim,

(8) Litigated: Out or Court Settlement (DOJ)

by Agreement

Non-Meritorious

(9) Other (Specify)

f. AMOUNT PAID

g. NUMBER OF CLAIMS FOR THIS INCIDENT

h. NUMBER OF PRACTITIONERS ON WHOSE BEHALF

PAYMENT WAS MADE

DD FORM 2526, FEB 2000

Page 2 of 4 Pages

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Dd Form 2526 - Case Abstract For Malpractice Claims Page 2

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