Loading
Form preview picture

Get Da 4700 2003-2024

Exception revision approved by APD 23 Feb 2009 Continue on reverse DEPARTMENT/SERVICE/CLINIC PREPARED BY Signature Title PATIENT S IDENTIFICATION For typed or written entries give first middle grade date hospital or medical facility Name DATE YYYYMMDD last HISTORY/PHYSICAL FLOW CHART OTHER EXAMINATION OR EVALUATION OTHER Specify DIAGNOSTIC STUDIES TREATMENT DA FORM 4700 FEB 2003 EDITION OF MAY 78 IS OBSOLETE. MEDCOM OP 40 DASG-HSZ FEB 2009 MC PE v2. MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form see AR 40-66 the proponent agency is the Office of The Surgeon General* REPORT TITLE OTSG APPROVED Date Respite Care Eligibility Review YYYYMMDD The Army through its Family and Morale Welfare and Recreation Command FMWRC is offering respite care to exceptional family members EFMs who meet one or more of the eligibility criteria listed below. A medical provider must indicate whether the EFM meets one or more of the following criteria* 1. Little or no age appropriate self-help skills. 2. Severe continuous seizures activity. 3. Ambulation with neurological impairment that requires assistance with activities of daily living. 4. Tube feeding. 5. Tracheotomy with frequent suctioning. 6. Apnea monitoring during hours of sleep if another family member must remain awake during monitoring. 7. Inability to control behavior with safety issues requiring constant supervision* 8. Life threatening or chronic condition requiring frequent hospitalizations or treatment encounters which require extensive family involvement in care giving. The limitation is permanent. or The Individual does NOT meet any of the above eight eligibility criteria* Provide a copy of this form to the family for submission to the installation Exceptional Family Member Program Manager. MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form see AR 40-66 the proponent agency is the Office of The Surgeon General* REPORT TITLE OTSG APPROVED Date Respite Care Eligibility Review YYYYMMDD The Army through its Family and Morale Welfare and Recreation Command FMWRC is offering respite care to exceptional family members EFMs who meet one or more of the eligibility criteria listed below. A medical provider must indicate whether the EFM meets one or more of the following criteria* 1. Little or no age appropriate self-help skills. A medical provider must indicate whether the EFM meets one or more of the following criteria* 1. Little or no age appropriate self-help skills. 2. Severe continuous seizures activity. 3. Ambulation with neurological impairment that requires assistance with activities of daily living. 2. Severe continuous seizures activity. 3. Ambulation with neurological impairment that requires assistance with activities of daily living. 4. Tube feeding. 5. Tracheotomy with frequent suctioning. 6. Apnea monitoring during hours of sleep if another family member must remain awake during monitoring. 4. Tube feeding. 5. Tracheotomy with frequent suctioning. 6. Apnea monitoring during hours of sleep if another family member must remain awake during monitoring. 7. Inability to control behavior with safety issues requiring constant supervision* 8. Life threatening or chronic condition requiring frequent hospitalizations or treatment encounters which require extensive family involvement in care giving. .

How It Works

fsis form 4700 rating
4.9Satisfied
374 votes

Tips on how to fill out, edit and sign Da 4700 fillable online

How to fill out and sign Da form 4700 online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Business, tax, legal and other electronic documents demand an advanced level of compliance with the legislation and protection. Our templates are updated on a regular basis according to the latest legislative changes. Additionally, with us, all of the details you provide in the DA 4700 is well-protected from leakage or damage with the help of cutting-edge encryption.

The following tips will help you fill out DA 4700 quickly and easily:

  1. Open the template in our full-fledged online editing tool by hitting Get form.
  2. Fill out the required fields that are yellow-colored.
  3. Press the green arrow with the inscription Next to move from box to box.
  4. Go to the e-autograph tool to e-sign the template.
  5. Put the date.
  6. Double-check the entire e-document to be sure that you haven?t skipped anything important.
  7. Click Done and save the new template.

Our platform allows you to take the entire process of completing legal forms online. Due to this, you save hours (if not days or weeks) and get rid of unnecessary costs. From now on, complete DA 4700 from your home, office, and even while on the move.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing da4700

Utilize our swift video guide for finishing Form in your browser. Turning to paperless is the only method to save your time for more significant tasks in the digitised age.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to DA 4700

  • YYYYMMDD
  • 2009
  • hsz
  • 2003
  • EFM
  • V2
  • FMWRC
  • OTSG
  • V1
  • EFMs
  • MEDCOM
  • 01ES
  • dasg
  • ambulation
  • Hospitalizations
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.