| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | associated request | 0;1 | POINTER | 162.2 | B | This is the report of contact associated with a notification/ request in contract hospital. |
| 1 | vendor(+) | 0;2 | POINTER | 161.2 | This is the Fee Basis Vendor, associated with the Contract Hospital Notification/Request. | |
| 2 | veteran | 0;3 | POINTER | 2 | D | This is the name of the veteran who is requesting contract hospital services from the VA. |
| 3 | initial date of contact | 0;4 | DATE-TIME | This field corresponds to the Date/Time field of the Fee Notification/Request file. | ||
| 4 | authorization from date | 0;5 | DATE-TIME | This field contains the date/time of admission of the veteran. | ||
| 5 | type of contact(+) | 0;6 | SET OF CODES | T:telephone P:personal | This is a way of identifying how the report of contact was initiated. | |
| 6 | person contacted | 0;7 | FREE TEXT | This is the name of the person who called. | ||
| 6.5 | phone # of person contacted | 1;4 | FREE TEXT | The phone number of the person with whom initial contact was made. | ||
| 7 | street address[1] of contact | 0;8 | FREE TEXT | This is the street address of person who called. | ||
| 8 | street address[2] of contact | 0;9 | FREE TEXT | This is a continuation line for the street address of the person who called. | ||
| 9 | city of contact | 0;10 | FREE TEXT | This is the city of the person who called. | ||
| 10 | state of contact | 0;11 | POINTER | 5 | This is the state of the person who called. | |
| 11 | zip code of contact | 0;12 | FREE TEXT | This is the zip code associated with the address of the person who called. | ||
| 12 | attending physician | 0;13 | FREE TEXT | This is the name of the attending physician treating the patient at the contract hospital. | ||
| 13 | attend.physician telephone no. | 0;14 | FREE TEXT | This is the number where the attending physician may be reached. | ||
| 14 | tentative diagnosis | 1;1 | FREE TEXT | Initial diagnosis given at the time of notification. | ||
| 15 | insurance type | 1;2 | FREE TEXT | This allows the user to document any other insurance the veteran may have. | ||
| 16 | mode of transportation | 1;3 | POINTER | 392.4 | This field allows the user to enter in the planned transportation of the veteran at time of transfer from contract hospital. | |
| 16.5 | veteran have other insurance | 1;5 | FREE TEXT | If the user answers 'Yes' to this question then they will be asked Insurance type. | ||
| 17 | date/time of contact | 2;0 | MULTIPLE | 161.517 | This multiple allows the CH user to enter contacts that were made with the VA on behalf of a patient who was admitted to a non-VA facility for treatment. | |
| 18 | approving official | 1;6 | POINTER | 200 | This is the official who is approving/disapproving the contract hospitalization. | |
| 19 | date/time of admission | 1;7 | DATE-TIME | The date and time the veteran was admitted to a non-VA facility for care. |
Not Referenced