NASA TREAT Astronauts Act

TREAT Astronaut Act text

1. Privacy Screenshot.

Privacy Act Notification

Furnishing us this information is voluntary. Failure to provide this information may result in NASA’s inability to track you for health monitoring and follow-up.

The Flight Medicine Clinic (FMC) will use this information to maintain accurate records to render routine care. Its collection is authorized by 42 USC § 2473; 44 USC § 3101; Pub L. 92-255 and managed under NASA 10HIMS, Health and Information Management System. NASA FMC may share your information, together with medical information for the following purposes, called routine uses: (1) this system of records may be granted to Federal, State, or local agencies or to foreign governments in cases of accident investigations, including mishap and collateral investigations; and (2) other entities outlined as Routine Uses in NASA 10HIMS and in NASA Standard Routine uses for all NASA systems of records. The full System of Records notice and Standard Routine Uses may be found at https://www.nasa.gov/content/nasa-privacy-act-system-of-records-notices-sorns.

Paperwork Reduction Act Notification

This information collection meets the requirements of 44 U.S.C § 3507 as amended by section 2 of the

Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid

Office of Management and Budget (OMB) control number. The OMB control number for this collection is 2700-0171 and this information collection expires on 06/30/2022. We estimate that it will take 30 minutes/hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate to: [email protected].

2. Patient Registration Forms

   1. Patient Tab Form:

Patient lD: Status:

Last Name: Social Security No:

First Name: Patient Category:

Address 1: Language:

Address 2: Employment Status:

City: State: Home Location:

Country: Zip:

Birth Date/Time: Title:

Home Phone: Suffix: Sensitive Patient: Get Picture..

Cell Phone: Sex:

Work Phone: Marital: Users denied access to the patient:

Fax: Ethnicity:

Pager: Race:

American Indian

Asian

Chinese

Filipino

Japanese

Native Hawaiian or Other Pacific Islander

Black or African

White

Patient Declines

State Prohibited

Hispanic

Other

Undetermined

Multiracial

E-mail:

Contact By: Items selected:

Registration Notes: Checked = may access with patient:

2. Insurance Tab Form:

Patient Insurance Plans:

Type: Company: Plan: Insurance Company:

. Phone:

Fax:

E-mail:

Contact:

Patient’s Plan Information:

Insured Party: Insurance Plan:

Group No: Name:

ID No: Contact:

Effective: Comments:

Termination:

New: Note: Changes made in this section cannot be canceled.

3. Contacts Tab Form

Contacts: Details..

Name: Phone:

Relationship: E-mail:

Contact by:

Contact:

Comments:

New: Note: Changes made in this section cannot be canceled.

4. Registry Tab Form

Opt In:

Registry:

Registry Type:

Opt-In Date:

Opt-out Date:

Opt-In Method:

Public Database:

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