Dd Form 2499 PDF Details

In the landscape of healthcare regulation and oversight, the DD Form 2499 plays a pivotal role, especially within military medical treatment facilities (MTFs). This form, officially known as the Health Care Practitioner Action Report, serves as a comprehensive reporting tool for documenting significant actions taken against healthcare practitioners. Ranging from initial privileges granted to a practitioner to modifications such as revocations or suspensions due to various reasons including substance abuse, incompetence, or negligence, the form captures a wide array of practitioner-related actions. Additionally, it provides a systematic way to report on less severe administrative measures and any alterations to a practitioner's status. The DD Form 2499 includes sections for detailed practitioner information, the type of report being filed, actions taken (including the reason and duration), and any professional licensure details. This form not only facilitates transparency and accountability within military healthcare settings but also supports the broader objective of maintaining high standards of care. Through its structured reporting of practitioner credentials and actions taken due to misconduct or incompetence, the DD Form 2499 contributes to the integrity of healthcare delivery systems and ensures that healthcare professionals within the military meet the requisite standards of professionalism and competency.

QuestionAnswer
Form NameDd Form 2499
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names14a, PRIVILEGING, YYYYMMDD, NPDB

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

1 . DATE OF REPORT (YYYYMMDD)

REPORT CONTROL SYMBOL

 

HEALTH CARE PRACTITIONER ACTION REPORT

 

 

 

 

 

 

 

 

 

 

 

DD-HA(AR)1611

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2 . TYPE OF REPORT (X one)

 

 

 

 

3 . DATE OF ACTION (YYYYMMDD)

4 . EFFECTIVE DATE OF

 

a. INITIAL

 

 

 

c. REVISION TO ACTION

 

 

 

 

 

 

 

 

 

 

ACTION (YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. CORRECTION OR ADDITION

 

d. VOID PREVIOUS REPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5 . MEDICAL TREATMENT FACILITY (MTF)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. NAME

 

 

 

b. ADDRESS (Street, City, State, ZIP Code)

 

 

 

c. DMIS CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6 . PRACTITIONER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. NAME (Last, First, Middle)

 

 

 

 

b. SSN

c. DATE OF BIRTH (YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

d. NAME OF PROFESSIONAL SCHOOL ATTENDED

 

 

 

(1) Unit ed St at es

e. DATE GRADUATED (YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

(2) Foreign

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f . STATUS (X one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) Army

 

 

(3) Air Force

 

(5) Civilian GS

 

 

 

(7) Part nership Ext ernal

 

 

 

 

 

(9) Non-Personal

 

 

 

 

 

 

 

 

 

 

 

 

 

(2) Navy

 

 

(4) PHS

 

(6) Part nership Int ernal

 

 

 

(8) Personal Services Cont ract

 

 

 

Services Cont ract

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. SOURCE OF ACCESSION (X all that apply)

 

 

 

 

 

 

 

 

 

h. PAY GRADE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) Milit ary

 

 

 

 

 

 

(2) Civilian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a) Volunt eer

 

 

 

(d) Nat ional Guard

 

 

 

(a) Civil Service

 

 

 

i. FEDERAL DEA NUMBER

 

(b) Armed Forces Healt h Pro-

 

(e) Reserve

 

 

 

(b) Cont ract ed

 

 

 

 

(If know n)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f essional Scholarship Program

 

(f ) Ot her (Specify)

 

 

 

(c) Consult ant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(c) Unif ormed Services Univer-

 

 

 

 

 

 

(d) Foreign Nat ional (Local Hire)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sit y of Healt h Sciences

 

 

 

 

 

 

(e) Ot her (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

j. LICENSING INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) St at e of License

 

(2) License Number

 

 

 

(1) St at e of License

 

 

 

 

(2) License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7 . 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 Specializat ion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a) Board Cert if ied

 

 

 

(b) Residency Complet ed

 

 

 

(c) In Residency (015/025)

 

 

 

 

(d) No Residency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2) Primary Specialt y

 

 

(h) Int ernal Medicine (Continued)

 

 

 

(l) Ot orhinolaryngology

 

 

(t ) Surgery, General (Continued)

 

(a) In Training

 

 

 

(h.c) Inf ect ious Disease

 

 

 

(m) Ort hopedics

 

 

 

 

(t .d) Oncology

 

 

 

 

 

 

 

 

 

 

 

 

(b) General Pract ice (GMO)

 

 

(h.d) Nephrology

 

 

 

(n) Pat hology

 

 

 

 

(t .e) Pediat ric

 

 

 

 

 

 

 

 

 

 

 

(c) Anest hesiology

 

 

 

(h.e) Pulmonary

 

 

 

(o) Pediat rics

 

 

 

 

(t .f ) Peripheral Vascular

 

 

 

 

 

 

 

 

 

 

 

 

(d) Aviat ion Medicine

 

 

(h.f ) Rheumat ology

 

 

 

(p) Physical Medicine

 

 

 

 

(t .g) Plast ic

 

 

 

 

 

 

 

 

 

 

 

(e) Dermat ology

 

 

 

(h.g) Tropical Medicine

 

 

 

(q) Prevent ive Medicine

 

 

 

 

 

 

 

 

 

 

 

 

 

(u) Underseas Medicine

 

(f ) Emergency Medicine

 

 

(h.h) Allergy/Immunology

 

 

 

(r) Psychiat ry

 

 

(v) Urology

 

 

 

 

 

 

 

 

 

(g) Family Pract ice

 

 

 

(h.i) Cardiology

 

 

 

(s) Radiology

 

 

(w ) Int ensivist

 

 

 

 

 

 

 

 

 

 

(h) Int ernal Medicine

 

 

(h.j) Endocrinology

 

 

 

(t ) Surgery, General

 

 

(x) Neonat ologist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(y) Ot her (Specify)

 

 

(h.a) Gast roent erology

 

(i) Neurology

 

 

 

 

(t .a) Cardio-Thoracic

 

 

 

 

(h.b) Hemat ology -

 

(j) Obst et rics/Gynecology

 

 

 

 

(t .b) Colon-Rect al

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oncology

 

 

(k) Opht halmology

 

 

 

 

(t .c) Neurosurgery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3) Board Cert if icat ion(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. DENTIST

 

 

 

DENTIST (030)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) Highest Level of Specializat ion

 

 

 

(2) Primary Specialt y

 

 

 

 

 

 

 

(a) Board Cert if ied

 

 

 

(c) In Residency (035)

 

 

 

(a) General Dent al Of f icer

 

 

 

(c) Ot her (Specify)

 

 

 

 

 

 

 

 

 

 

 

(b) Residency Complet ed

 

(d) No Residency

 

 

 

(b) Oral Surgeon

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3) Board Cert if icat ion(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. OTHER PRACTITIONERS

 

OTHER PRACTITIONERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Audiologist (400)

 

 

 

Nurse Anest het ist (110)

 

 

 

Opt omet rist (636)

 

 

Regist ered Nurse (100)

 

Clinical Diet ician (200)

 

Nurse Midw if e (120)

 

 

 

Physical Therapist (430)

 

 

Emergency Medical

 

 

 

 

 

 

 

 

Clinical Pharmacist (050)

 

Nurse Pract it ioner (130)

 

 

 

Physician Assist ant (642)

 

 

 

Technician

 

 

 

 

 

 

 

 

 

Clinical Psychologist (370)

 

Occupat ional Therapist

 

 

 

Podiat rist (350)

 

 

Ot her (Specify)

 

 

 

 

 

 

 

 

Clinical Social Worker (300)

 

(410)

 

 

 

Speech Pat hologist (450)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DD FORM 2499, FEB 2000

 

PREVIOUS EDITION IS OBSOLETE.

 

 

 

 

 

Page 1 of 3 Pages

Adobe Professional 7.0

8

. ACTION TAKEN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. PRIVILEGING ACTIONS TAKEN/REASON CODE

b. ACTIONS OTHER THAN PRIVILEGING (ADMINISTRATIVE)/

c. LENGTH OF ACTION

 

(See Page 3, Item 14a)

 

REASON CODES (See Page 3, Item 14b)

 

 

(In months)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NONE

 

 

NONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. LIST HOW AND WHY WHAT PRIVILEGES ARE AFFECTED BY THE ACTION:

 

 

 

 

 

 

 

 

 

 

 

 

e. OTHER ACTIONS TAKEN (X all that apply)

 

 

 

 

 

 

 

 

 

(1) Review

 

(3) Ret raining

 

(5) Separat ed f or Cause

 

 

(7) Separat ed

 

(9) Ret ired

 

 

 

 

 

 

 

 

 

 

 

(2) Rehabilit at ion

 

(4) On-t he-Job Training

 

(6) Fired/Terminat ed

 

 

(8) Resigned

 

(10) Ot her

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

. CIVILIAN CONTRACTOR NAME

 

 

 

 

 

 

 

 

 

10

. PRACTITIONER' S LAST KNOWN ADDRESS OR HOME OF

11 . MEDICAL TREATMENT FACILITY (MTF) POINT OF CONTACT

 

 

RECORD (Street,Apartment/Suite Number, City, State, ZIP Code)

 

 

 

 

a. NAME (Last, First, Middle Initial)

b. TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Include Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

12

. REMARKS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13

. OFFICE OF THE SURGEON GENERAL (OTSG) INDIVIDUAL SUBMITTING REPORT

 

 

 

 

 

 

 

 

a. NAME (Last, First, Middle Initial)

b. TITLE

 

 

c. TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

d. ADDRESS

 

 

 

 

e. SIGNATURE

 

 

f . DATE SIGNED

 

 

Office of the

Surgeon General

 

 

 

 

 

(YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

 

 

 

 

 

 

 

 

(All other items are self -explanatory.)

 

 

 

2b.

Correction or Addition. An administ rat ive change int ended t o supersede or add inf ormat ion t o t he cont ent s of t he current version of

 

 

 

a report .

 

 

 

 

 

 

 

 

 

 

2c.

Revision to Action. A new act ion w hich is relat ed t o and modif ies a previously submit t ed adverse act ion.

 

3

.

 

Date of Action. Ent er t he dat e of f ormal approval of t he MTFs act ion as indicat ed by t he OTSG.

 

4

.

 

Effective Date of Action.

Ent er t he dat e on w hich t he act ion became ef f ect ive.

 

 

 

14a.

Privileging Actions Taken/Reason. This ent ry is equivalent t o NPDB' s Adverse Act ion Classif icat ion Code.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DD FORM 2499, FEB 2000

Page 2 of 3 Pages

14a. PRIVILEGING ACTIONS TAKEN/REASON CODES

610

REVOCATION - CLINICAL PRIVILEGES

645

OTHER RESTRICTION - CLINICAL PRIVILEGES

 

610.01

Alcoholism and Ot her Subst ance Abuse

 

645.01

Alcoholism and Ot her Subst ance Abuse

 

610.02

Incompet ence/Malpract ice/Negligence

 

645.02

Incompet ence/Malpract ice/Negligence

 

610.03

Narcot ics Violat ions

 

645.03

Narcot ics Violat ions

 

610.04

Felony

 

645.04

Felony

 

610.05

Fraud

 

645.05

Fraud

 

610.10

Unprof essional Conduct

 

645.10

Unprof essional Conduct

 

610.20

Ment al Disorder

 

645.20

Ment al Disorder

 

610.30

Allow ing Unlicensed Person t o Pract ice

 

645.30

Allow ing Unlicensed Person t o Pract ice

 

610.50

Disciplinary Act ion Taken in Anot her St at e

 

645.50

Disciplinary Act ion Taken in Anot her St at e

 

610.70

Violat ed Previous Act ion

 

645.70

Violat ed Previous Act ion

 

610.80

Physical Impairment

 

645.80

Physical Impairment

 

610.90

Ot her

 

645.90

Ot her

 

 

 

 

630

SUSPENSION - CLINICAL PRIVILEGES

650

DENIAL (ORIGINAL OR SUBSEQUENT) -

 

630.01 Alcoholism and Ot her Subst ance Abuse

 

CLINICAL PRIVILEGES

 

 

 

 

 

 

 

630.02

Incompet ence/Malpract ice/Negligence

 

650.01

Alcoholism and Ot her Subst ance Abuse

 

630.03 Narcot ics Violat ions

 

650.02 Incompet ence/Malpract ice/Negligence

 

 

 

 

 

630.04

Felony

 

650.03 Narcot ics Violat ions

 

630.05

Fraud

 

 

 

650.04

Felony

 

630.10 Unprof essional Conduct

 

 

 

650.05

Fraud

 

630.20

Ment al Disorder

 

 

 

650.10 Unprof essional Conduct

 

630.30 Allow ing Unlicensed Person t o Pract ice

 

 

 

650.20

Ment al Disorder

 

630.50 Disciplinary Act ion Taken in Anot her St at e

 

 

 

 

 

 

630.70 Violat ed Previous Act ion

 

650.30 Allow ing Unlicensed Person t o Pract ice

 

 

 

 

 

630.80

Physical Impairment

 

650.50

Disciplinary Act ion Taken in Anot her St at e

 

630.90

Ot her

 

650.70

Violat ed Previous Act ion

 

 

 

 

650.80

Physical Impairment

 

 

 

 

650.90

Ot her

635VOLUNTARY SURRENDER OF ALL PRIVILEGES WHILE UNDER INVESTIGATION FOR INCOMPETENCE OR

MISCONDUCT OR TO AVOID SUCH INVESTIGATION -

680 - 699

REVISION TO ACTION - CLINICAL PRIVILEGES

CLINICAL PRIVILEGES

 

 

 

635.01 Alcoholism and Ot her Subst ance Abuse

680.00 Reinst at ement , Complet e

681.00 Reinst at ement , Condit ional

635.02 Incompet ence/Malpract ice/Negligence

689.00 Reinst at ement , Denied

635.03 Narcot ics Violat ions

 

 

 

635.04

Felony

690.00

Part ial Reinst at ement of Privileges -

 

 

 

635.05

Fraud

 

 

Reduct ion of Previous Act ion

635.10

Unprof essional Conduct

695.00

Ext ension of Previous Act ion

635.20

Ment al Disorder

699.00

Reversal of Previous Act ion Due t o Appeal or

635.30

Allow ing Unlicensed Person t o Pract ice

 

 

Review

635.50 Disciplinary Act ion Taken in Anot her St at e

 

 

 

635.70 Violat ed Previous Act ion

14b. ACTIONS OTHER THAN PRIVILEGING (ADMINISTRATIVE)/

635.80

Physical Impairment

REASON CODES

 

 

635.90 Ot her

 

 

 

 

 

810.01 Alcoholism and Ot her Subst ance Abuse

640 REDUCTION IN PRIVILEGES - CLINICAL PRIVILEGES

810.02 Ref erral f or Court s Mart ial

 

 

 

 

 

810.03 Narcot ics Violat ions

640.01 Alcoholism and Ot her Subst ance Abuse

810.04

Felony

640.02 Incompet ence/Malpract ice/Negligence

810.05

Fraud

640.03 Narcot ics Violat ions

 

 

 

640.04

Felony

810.10 Unprof essional Conduct

 

 

 

640.05

Fraud

810.20

Ment al Disorder

640.10

Unprof essional Conduct

810.30

Allow ing Unlicensed Person t o Pract ice

640.20

Ment al Disorder

810.50 Disciplinary Act ion Taken in Anot her St at e

 

 

640.30 Allow ing Unlicensed Person t o Pract ice

810.70 Violat ed Previous Act ion

640.50 Disciplinary Act ion Taken in Anot her St at e

810.80

Physical Impairment

640.70 Violat ed Previous Act ion

 

 

 

640.80

Physical Impairment

810.90 Ot her

 

 

 

640.90 Ot her

 

 

 

 

 

 

 

DD FORM 2499, FEB 2000

 

 

Page 3 of 3 Pages

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When it comes to blank fields of this specific PDF, here's what you need to do:

1. Fill out your 2000 with a selection of essential blanks. Consider all of the necessary information and make certain there is nothing forgotten!

GMO completion process clarified (stage 1)

2. The next part would be to submit these blanks: b Armed Forces Health Pro, c Uniformed Services Univer sity, j LICENSING INFORMATION, e Reserve f Other Specify, c Consultant d Foreign National, State of License, License Number, State of License, License Number, TYPE OF PRACTITIONER AND, Highest Level of Specialization, a Board Certified, b Residency Completed, c In Residency, and d No Residency.

Ways to prepare GMO part 2

3. Completing Highest Level of Specialization, Primary Specialty, a Board Certified, c In Residency, a General Dental Officer, c Other Specify, b Residency Completed, d No Residency, b Oral Surgeon, Board Certifications, c OTHER PRACTITIONERS, OTHER PRACTITIONERS, Audiologist, Nurse Anesthetist, and Optometrist is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

c OTHER PRACTITIONERS, a Board Certified, and d No Residency inside GMO

4. You're ready to start working on this next part! Here you have all of these a PRIVILEGING ACTIONS TAKENREASON, b ACTIONS OTHER THAN PRIVILEGING, c LENGTH OF ACTION In months, NONE, NONE, d LIST HOW AND WHY WHAT PRIVILEGES, e OTHER ACTIONS TAKEN X all that, Review, Separated for Cause, Separated, Rehabilitation, OntheJob Training, FiredTerminated, Resigned, and CIVILIAN CONTRACTOR NAME blank fields to complete.

GMO conclusion process explained (step 4)

People frequently make mistakes when completing c LENGTH OF ACTION In months in this part. Ensure you double-check whatever you type in right here.

5. This last notch to finalize this PDF form is critical. Make certain you fill in the necessary form fields, like REMARKS, OFFICE OF THE SURGEON GENERAL, b TITLE, d ADDRESS Office of the, Surgeon General, e SIGNATURE, c TELEPHONE NUMBER, f DATE SIGNED YYYYMMDD, INSTRUCTIONS, All other items are selfexplanatory, and b Correction or Addition An, before submitting. Failing to do this can result in an unfinished and possibly nonvalid form!

Tips to fill out GMO part 5

Step 3: Ensure that the information is correct and then click "Done" to continue further. Create a 7-day free trial option with us and acquire instant access to 2000 - download or modify from your FormsPal account page. Whenever you work with FormsPal, you can fill out forms without having to be concerned about personal data leaks or entries getting distributed. Our protected platform helps to ensure that your personal data is kept safely.