Form Navmed 6100 5 PDF Details

The Department of Defense has published a new form, Navmed 6100-5, that pertains to reimbursement for medical services and supplies. This form must be used by all military personnel and their families who seek reimbursement for out-of-pocket medical expenses. The purpose of this form is to ensure that all reimbursements are processed in a timely and accurate manner. Navmed 6100-5 is now available on the Defense Finance and Accounting Service website.

QuestionAnswer
Form NameForm Navmed 6100 5
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names6100 5, navmed 6100 5, PERS-4821

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ABBREVIATED MEDICAL EVALUATION BOARD REPORT

SECTION 1: CLINICAL INFORMATION (TO BE COMPLETED BY MEDICAL OFFICERS)

Date:

 

Patient Name:

 

Patient SSN:

 

 

 

 

 

Proposed start date for limited duty:

Proposed end date (< 6 months):

This period of limited duty is for: (Select one)

1st LIMDU (< 6 months) Enlisted ADSM (no referral to service headquarters necessary).

2nd LIMDU (< 6 months) Enlisted ADSM (no referral to service headquarters necessary). Note that the first and second TLD periods cannot exceed 12 months cumulatively from the date of the first TLD period.

1st LIMDU (< 6 months) Officer ADSM (referral to service headquarters necessary).

2nd LIMDU (< 6 months) Officer ADSM (referral to service headquarters necessary).

3rd or subsequent LIMDU periods on Navy and Marine ADSM involving a distinctly different condition than that responsible for the first and second TLD periods (for referral to service headquarters for "departmental review").

Placement on LIMDU - if the patient is not already in a LIMDU status - at the same time the patient's case is referred to the physical evaluation board for adjudication.

Diagnosis: (1)

ICD-9 CM Code

(2)

 

ICD-9 CM Code

(3)

 

ICD-9 CM Code

 

Circumstances of injury/illness:

 

Treatment plan:

Limitations from full duty (including whether transfer/TEMDU for treatment is indicated, and any PRT limitations):

Printed MEB Member Name and Signature/Date

Printed MEB Member Name and Signature/Date

Printed CA Name and Signature/Date

SECTION 2: PATIENT INFORMATION, TO BE COMPLETED BY PATIENT

I have received full information on the proposed Limited Duty period from my provider. I understand that this period of limited duty is not effective until approved by the MTF Convening Authority, and that the MTF will report this LIMDU action to my parent command. I understand I may be returned to duty prior to the date appearing above as my clinical condition warrants and upon action by my attending provider.

Patient Signature/Date

SECTION 3: TO BE COMPLETED BY PATIENT ADMINISTRATION OFFICER/MEDICAL BOARDS OFFICER

The following actions have been completed:

Completion of Patient Information Sheet

Notification to PSD/Personnel Office

LODD Requested from Parent Command (if LODD required)

Entry into MedBOLTT

Briefing to Patient on Limited Duty/MEBs

Notification to MTF LIMDU Coordinator

Notification to Parent Command

Patient Administration Officer/Medical Boards Official Printed Name, Signature, and Date

ROUTING: Original to Patient Health Record; copies to Patient, Parent Command, PSD,

NAVMED 6100/5 (Rev. 08-2004)

MEBR Case File, and PERS-4821 or MMSR-4

PREVIOUS EDITIONS OBSOLETE

 

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Writing part 1 of 6100 5

2. Just after completing this section, go to the subsequent part and enter the necessary particulars in all these fields - Limitations from full duty, Printed MEB Member Name and, Printed MEB Member Name and, Printed CA Name and SignatureDate, SECTION PATIENT INFORMATION TO BE, I have received full information, Patient SignatureDate, SECTION TO BE COMPLETED BY, The following actions have been, Completion of Patient Information, Notification to PSDPersonnel Office, Briefing to Patient on Limited, Notification to MTF LIMDU, LODD Requested from Parent Command, and Notification to Parent Command.

Simple tips to fill in 6100 5 portion 2

People frequently make errors while filling out Limitations from full duty in this area. Don't forget to read again whatever you enter right here.

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