Fillable Printable Request For Private Medical Information
Fillable Printable Request For Private Medical Information
Request For Private Medical Information
10. Date (YYYYMMDD)
8. Summary of Private Medical Information Released.
9. Signature of Approving Official.
1. Date (YYYYMMDD)
2. Patient's Name and SSN.
3. Medical Treatment Facility (Name and Location)
4. Reason for Request.
5. Private Medical Information Sought (Specify dates of hospitalization or clinic visits and diagnosis, if known)
6. Requestor's Name, Title, Organization and SSN.
Disapproved (State reason for disapproval)
REQUEST FOR PRIVATE MEDICAL INFORMATION
For use of this form, see AR 40-66; the proponent agency is the OTSG
DA FORM 4254, FEB 2003
APD LC v1.02ES
FOR USE OF MEDICAL TREATMENT FACILITY ONLY
7. Check applicable box.
DA FORM 4254-R, NOV 91, IS OBSOLETE.
Approved
