DA Form 5018-R Adapcp Client's Consent Statement for Release of Treatment Information (Lra)

DA Form 5018-R - also known as the "Adapcp Client's Consent Statement For Release Of Treatment Information (lra)" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 5018-R - was last revised on November 1, 1981. Download an up-to-date fillable PDF version of the DA 5018-R down below or look it up on the Army Publishing Directorate website.

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ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION
For use of this form, see AR 600-85; the proponent agency is DCS, G-1.
SECTION A - CONSENT
I,
, this
day of
20
,
(client's full name)
do hereby voluntarily consent to the release of the following information by
(name of installation ADAPCP)
pertaining to my identity, diagnosis, prognosis, or treatment from any Army record maintained in connection with
alcohol or other drug abuse education, training, treatment, rehabilitatiton, or research to
for the purpose of
namely,
(extent or nature of information to be disclosed)
SECTION B - EXPIRATION/REVOCATION
(Check applicable paragraph)
1.
I understand that this consent automatically expires when the above disclosure action has been taken in
reliance thereon and that, except to the extent that such action has been taken, I can revoke this consent at
any time.
- Or -
(For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b(4)(b) and 6-10e(3), AR 600-85)
2.
I understand that this consent automatically expires 60 days from today's date or when my present
criminal justice system status changes to
Further, I understand that if my release from confinement, probation, or parole is conditioned upon my
participation in the ADAPCP, I cannot revoke this consent until there has been a formal and effective
termination or revocation of my release from such confinement, probation, or parole.
SIGNATURE OF CLIENT
DATE
NAME OF WITNESS (Type or print)
SIGNATURE
DATE
SECTION C - APPROVAL AUTHORITY FOR RELEASE OF INFORMATION
NOTE:
Other than the MEDCEN/MEDDAC Commander, approval authority for release of information may be delegated to the Program
Physician or the Clinical Director.
In my judgment, the release of an evaluation of the present or past status of
(client's name)
in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her.
NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE (Type or print)
DATE
SIGNATURE
DA FORM 5018-R, NOV 1981
APD LC v3.00ES
ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION
For use of this form, see AR 600-85; the proponent agency is DCS, G-1.
SECTION A - CONSENT
I,
, this
day of
20
,
(client's full name)
do hereby voluntarily consent to the release of the following information by
(name of installation ADAPCP)
pertaining to my identity, diagnosis, prognosis, or treatment from any Army record maintained in connection with
alcohol or other drug abuse education, training, treatment, rehabilitatiton, or research to
for the purpose of
namely,
(extent or nature of information to be disclosed)
SECTION B - EXPIRATION/REVOCATION
(Check applicable paragraph)
1.
I understand that this consent automatically expires when the above disclosure action has been taken in
reliance thereon and that, except to the extent that such action has been taken, I can revoke this consent at
any time.
- Or -
(For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b(4)(b) and 6-10e(3), AR 600-85)
2.
I understand that this consent automatically expires 60 days from today's date or when my present
criminal justice system status changes to
Further, I understand that if my release from confinement, probation, or parole is conditioned upon my
participation in the ADAPCP, I cannot revoke this consent until there has been a formal and effective
termination or revocation of my release from such confinement, probation, or parole.
SIGNATURE OF CLIENT
DATE
NAME OF WITNESS (Type or print)
SIGNATURE
DATE
SECTION C - APPROVAL AUTHORITY FOR RELEASE OF INFORMATION
NOTE:
Other than the MEDCEN/MEDDAC Commander, approval authority for release of information may be delegated to the Program
Physician or the Clinical Director.
In my judgment, the release of an evaluation of the present or past status of
(client's name)
in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her.
NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE (Type or print)
DATE
SIGNATURE
DA FORM 5018-R, NOV 1981
APD LC v3.00ES

Download DA Form 5018-R Adapcp Client's Consent Statement for Release of Treatment Information (Lra)

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