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Get Form 4254 2003-2024

Signature of Approving Official. DA FORM 4254 FEB 2003 DA FORM 4254-R NOV 91 IS OBSOLETE. USAPA V1. U.S. DOD Form dod-da-4254 REQUEST FOR PRIVATE MEDICAL INFORMATION 1. Date YYYYMMDD For use of this form see AR 40-66 the proponent agency is the OTSG 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* FOR USE OF MEDICAL TREATMENT FACILITY ONLY 7. Check applicable box. Approved Disapproved State reason for disapproval 8. Summary of Private Medical Information Released* 9. 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* FOR USE OF MEDICAL TREATMENT FACILITY ONLY 7. Check applicable box. Requestor s Name Title Organization and SSN* FOR USE OF MEDICAL TREATMENT FACILITY ONLY 7. Check applicable box. Approved Disapproved State reason for disapproval 8. Summary of Private Medical Information Released* 9. 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* FOR USE OF MEDICAL TREATMENT FACILITY ONLY 7. Check applicable box. Approved Disapproved State reason for disapproval 8. Summary of Private Medical Information Released* 9. .

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