DA Form 4159 Request for Medical Care in a Federal Medical Treatment Facility Outside Department of Defense

DA Form 4159 or the "Request For Medical Care In A Federal Medical Treatment Facility Outside Department Of Defense" 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 4159 - was last revised on May 1, 2009. Download an up-to-date fillable DA Form 4159 down below in PDF-format or look it up on the Army Publishing Directorate website.

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REQUEST FOR MEDICAL CARE IN A FEDERAL MEDICAL TREATMENT FACILITY
DATE
OUTSIDE DEPARTMENT OF DEFENSE
(For use of this form, see AR 40-400; the proponent agency is the Office of the Surgeon General)
PREPARE IN TRIPLICATE
TO: (Include ZIP Code)
FROM: (Include ZIP Code)
If this person is admitted as an inpatient, immediately notify the closest Army Medical Treatment facility for assumption
of administrative responsibility. Please furnish information regarding diagnosis, treatment, etc., necessary to complete
Army medical records and reports, upon request of the commander of the designated Army facility.
1. PATIENT'S NAME (Last, first, MI)
2. GRADE
3. ORGANIZATION
4. STATION TO WHICH ASSIGNED
5. LOCATION OF TRAINING SITE WHERE DISEASE OR INJURY
OCCURRED
PATIENT'S STATUS
6. PATIENT'S STATUS AS DUTY, PASS, LEAVE, ABSENT WITHOUT LEAVE, DELAY IN ROUTE (Specify)
7. PATIENT IS A MEMBER OF
8. PATIENT'S STATUS (*Inclusive dates of training)
INACTIVE DUTY FOR
USAR
ANG
AROTC
ACTIVE DUTY FOR TRAINING*
TRAINING*
OTHER (Specify)
OTHER (Specify)
9. IF KNOWN, STATE NATURE OF TREATMENT OR SERVICE REQUIRED WITH DIAGNOSIS
10. REASON FOR REQUESTING MEDICAL CARE IN A FEDERAL MEDICAL TREATMENT FACILITY OUTSIDE THE DEPARTMENT OF
DEFENSE (For USAR, ANG, AROTC on inactive duty training, and ANG on active duty training, date of occurrence of disease or injury and brief
description of events leading up to and surrounding the occurrence).
11. DISPOSITION INSTRUCTIONS UPON COMPLETION OF TREATMENT
TYPED NAME AND GRADE
SIGNATURE
DA FORM 4159, MAY 2009
PREVIOUS EDITIONS ARE OBSOLETE
APD LC v1.00ES
REQUEST FOR MEDICAL CARE IN A FEDERAL MEDICAL TREATMENT FACILITY
DATE
OUTSIDE DEPARTMENT OF DEFENSE
(For use of this form, see AR 40-400; the proponent agency is the Office of the Surgeon General)
PREPARE IN TRIPLICATE
TO: (Include ZIP Code)
FROM: (Include ZIP Code)
If this person is admitted as an inpatient, immediately notify the closest Army Medical Treatment facility for assumption
of administrative responsibility. Please furnish information regarding diagnosis, treatment, etc., necessary to complete
Army medical records and reports, upon request of the commander of the designated Army facility.
1. PATIENT'S NAME (Last, first, MI)
2. GRADE
3. ORGANIZATION
4. STATION TO WHICH ASSIGNED
5. LOCATION OF TRAINING SITE WHERE DISEASE OR INJURY
OCCURRED
PATIENT'S STATUS
6. PATIENT'S STATUS AS DUTY, PASS, LEAVE, ABSENT WITHOUT LEAVE, DELAY IN ROUTE (Specify)
7. PATIENT IS A MEMBER OF
8. PATIENT'S STATUS (*Inclusive dates of training)
INACTIVE DUTY FOR
USAR
ANG
AROTC
ACTIVE DUTY FOR TRAINING*
TRAINING*
OTHER (Specify)
OTHER (Specify)
9. IF KNOWN, STATE NATURE OF TREATMENT OR SERVICE REQUIRED WITH DIAGNOSIS
10. REASON FOR REQUESTING MEDICAL CARE IN A FEDERAL MEDICAL TREATMENT FACILITY OUTSIDE THE DEPARTMENT OF
DEFENSE (For USAR, ANG, AROTC on inactive duty training, and ANG on active duty training, date of occurrence of disease or injury and brief
description of events leading up to and surrounding the occurrence).
11. DISPOSITION INSTRUCTIONS UPON COMPLETION OF TREATMENT
TYPED NAME AND GRADE
SIGNATURE
DA FORM 4159, MAY 2009
PREVIOUS EDITIONS ARE OBSOLETE
APD LC v1.00ES

Download DA Form 4159 Request for Medical Care in a Federal Medical Treatment Facility Outside Department of Defense

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