Download DA Form 7574-1 Military Physician's Statement of Soldier's Incapacitation/Fitness for Duty
How to Fill out DA Form 7574-1?
An overview of the form and filing guidelines can be found in the Department of the Army Pamphlet 135-381, Incapacitation of Reserve Component Soldiers Processing Procedures, released in May 2008. DA Form 7574-1 instructions are as follows:
- The DA 7574-1 relates to the medical documentation pertaining to the treatment received by the soldier and should be completed when requesting incapacitation payments. The document contains two sections in total.
- Section I - Soldier Identification - is mostly self-explanatory. All boxes are completed by the soldier making the claim and require their personal identifying data. This information includes their name, SSN, rank, MI, duty MOS or AOC.
This part should also identify the service member's civilian occupation with a copy of the job description attached to the completed form.
- Section II - Incapacitation/Fitness for Duty Verification - consists of two parts. A soldier's incapacitation to perform military duties must be verified by U.S. Government or military physician. Incapacitation for a civilian job can be verified by any licensed physician.
All lines in Box 10 are completed by an attending government physician. Authorized personnel includes licensed government or military physicians, Reserve commissioned officers employed as licensed physicians by the Department of Veteran Affairs and non-military physicians employed by military services (DVA, TRICARE, MMSO).
The required information includes the diagnosis and prognosis, the date of the next follow-up appointment along with the physician's personal data and their signature.
DA 7574-1 Related Forms
- DA Form 7574, Incapacitation Pay Monthly Claim Form, used to determine the eligibility of the soldier to receive incapacitation pay.
- DA Form 7574-2, Soldier's Acknowledgement of Incapacitation Pay Counselling, by which the soldier testifies that they were properly informed on incapacitation pay claims.