DA Form 8004 Army Sustance Abuse Program (Asap) Outpatient Medical Records - Privacy Act Information

DA Form 8004 or the "Army Sustance Abuse Program (asap) Outpatient Medical Records - Privacy Act Information" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 8004 - was last revised on February 1, 2003. Download an up-to-date fillable DA Form 8004 down below in PDF-format or look it up on the Army Publishing Directorate website.

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ARMY SUSTANCE ABUSE PROGRAM (ASAP) OUTPATIENT
MEDICAL RECORDS - PRIVACY ACT INFORMATION
For use of this form, see AR 40-66; the proponent agency is the OTSG
This form is not a consent form to release or use health care information about you.
1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER
(SSN). Title V, Public Law 92-129; section 501, 42 USC section 290dd.
2. PRINCIPAL PURPOSES OF OUTPATIENT MEDICAL RECORDS.
a. To provide necessary information to evaluate the existence of and, if appropriate,
the nature and extent of the patient's alcohol and other drug problem.
b. To provide baseline information for monitoring the patient's progress during
rehabilitation in the ASAP.
c. To ensure continuity of care of patient enrolled in ASAP rehabilitation.
d. As part of the Active Army soldier's medical record, to provide information to
military physicians in diagnosing other medical problems and in prescribing medication.
e. To provide statistical information for program evaluation.
3. ROUTINE USES.
a. Active Army Soldiers. Release of any information from this record is subject to the restrictions
of 21 USC 1175 as amended by 88 Stat 137; 42 USC 4582 amended by 88 Stat 131 chapter 1, title
42, Code of Federal Regulations. Under these statutes and regulations, disclosure of information
that would identify the patient as an abuser of alcohol or other drugs is authorized within the Armed
Forces or to those components of the Veterans Administration furnishing health care to veterans.
AR 600-85 further limits disclosure within the Armed Forces to those individuals having an official
need to know (for example, the physician or the patient's unit commander). All other disclosures
require the written consent of the patient except disclosures (1) to medical personnel outside the
Armed Forces to the extent necessary to meet a bona fide medical emergency; (2) to qualified
personnel conducting scientific research, management, or financial competent jurisdiction.
b. Civilian employees and other personnel. Release of any information from this record is subject
to the restrictions of 21 USC 1175 as amended by 88 Stat 137- 42 USC 4582 as amended by 88
Stat 131 and chapter 1, title 42, Code of Federal Regulations. All disclosures require the written
consent of the patient except disclosures (1) to medical personnel to the extent necessary to meet a
bona fide medical emergency; (2) to qualified personnel conducting scientific research, management,
or financial audits or program evaluation or (3) upon the order of a court of competent jurisdiction.
4. MANDATORY / VOLUNTARY DISCLOSURE AND EFFECT ON AN INDIVIDUAL NOT
PROVIDING INFORMATION.
a. Disclosure is mandatory for Active Army soldiers. Failure to obey order from competent
authority to provide required information may be subject to appropriate disciplinary action under the
UCMJ.
b. Disclosure is voluntary for civilian employees and other personnel. The failure to disclose the
information will result in a reduced capability of the program to provide treatment and services.
5. Signature of Patient or Sponsor
6. SSN of Member or Sponsor.
7. Date
(YYYYMMDD)
DA FORM 8004, FEB 2003
DA FORM 8004-R, NOV 96, IS OBSOLETE.
APD LC v1.00
ARMY SUSTANCE ABUSE PROGRAM (ASAP) OUTPATIENT
MEDICAL RECORDS - PRIVACY ACT INFORMATION
For use of this form, see AR 40-66; the proponent agency is the OTSG
This form is not a consent form to release or use health care information about you.
1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER
(SSN). Title V, Public Law 92-129; section 501, 42 USC section 290dd.
2. PRINCIPAL PURPOSES OF OUTPATIENT MEDICAL RECORDS.
a. To provide necessary information to evaluate the existence of and, if appropriate,
the nature and extent of the patient's alcohol and other drug problem.
b. To provide baseline information for monitoring the patient's progress during
rehabilitation in the ASAP.
c. To ensure continuity of care of patient enrolled in ASAP rehabilitation.
d. As part of the Active Army soldier's medical record, to provide information to
military physicians in diagnosing other medical problems and in prescribing medication.
e. To provide statistical information for program evaluation.
3. ROUTINE USES.
a. Active Army Soldiers. Release of any information from this record is subject to the restrictions
of 21 USC 1175 as amended by 88 Stat 137; 42 USC 4582 amended by 88 Stat 131 chapter 1, title
42, Code of Federal Regulations. Under these statutes and regulations, disclosure of information
that would identify the patient as an abuser of alcohol or other drugs is authorized within the Armed
Forces or to those components of the Veterans Administration furnishing health care to veterans.
AR 600-85 further limits disclosure within the Armed Forces to those individuals having an official
need to know (for example, the physician or the patient's unit commander). All other disclosures
require the written consent of the patient except disclosures (1) to medical personnel outside the
Armed Forces to the extent necessary to meet a bona fide medical emergency; (2) to qualified
personnel conducting scientific research, management, or financial competent jurisdiction.
b. Civilian employees and other personnel. Release of any information from this record is subject
to the restrictions of 21 USC 1175 as amended by 88 Stat 137- 42 USC 4582 as amended by 88
Stat 131 and chapter 1, title 42, Code of Federal Regulations. All disclosures require the written
consent of the patient except disclosures (1) to medical personnel to the extent necessary to meet a
bona fide medical emergency; (2) to qualified personnel conducting scientific research, management,
or financial audits or program evaluation or (3) upon the order of a court of competent jurisdiction.
4. MANDATORY / VOLUNTARY DISCLOSURE AND EFFECT ON AN INDIVIDUAL NOT
PROVIDING INFORMATION.
a. Disclosure is mandatory for Active Army soldiers. Failure to obey order from competent
authority to provide required information may be subject to appropriate disciplinary action under the
UCMJ.
b. Disclosure is voluntary for civilian employees and other personnel. The failure to disclose the
information will result in a reduced capability of the program to provide treatment and services.
5. Signature of Patient or Sponsor
6. SSN of Member or Sponsor.
7. Date
(YYYYMMDD)
DA FORM 8004, FEB 2003
DA FORM 8004-R, NOV 96, IS OBSOLETE.
APD LC v1.00

Download DA Form 8004 Army Sustance Abuse Program (Asap) Outpatient Medical Records - Privacy Act Information

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