DA Form 4254 Request for Private Medical Information

DA Form 4254 - also known as the "Request For Private Medical Information" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 4254 - was last revised on February 1, 2003. Download an up-to-date fillable PDF version of the DA 4254 below or request a copy through the chain of command.

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1. Date
(YYYYMMDD)
REQUEST FOR PRIVATE MEDICAL INFORMATION
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. Signature of Approving Official.
10. Date
(YYYYMMDD)
DA FORM 4254, FEB 2003
APD LC v1.02ES
DA FORM 4254-R, NOV 91, IS OBSOLETE.
1. Date
(YYYYMMDD)
REQUEST FOR PRIVATE MEDICAL INFORMATION
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. Signature of Approving Official.
10. Date
(YYYYMMDD)
DA FORM 4254, FEB 2003
APD LC v1.02ES
DA FORM 4254-R, NOV 91, IS OBSOLETE.
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