DA Form 4876 Request and Release of Medical Information to Communications Media

DA Form 4876 - also known as the "Request And Release Of Medical Information To Communications Media" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 4876 - was last revised on April 1, 2010. Download an up-to-date fillable PDF version of the DA 4876 down below or look it up on the Army Publishing Directorate website.

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REQUEST AND RELEASE OF MEDICAL INFORMATION TO COMMUNICATIONS MEDIA
For use of this form see AR 40-66; the proponent agency is the Office of The Surgeon General.
PRIVACY ACT STATEMENT
AUTHORITY: Section 3012, title 10, United States Code.
PRINCIPAL PURPOSE(S): This form provides for patient/parent/guardian consent to release requested personal medical information to news
publication or broadcast.
ROUTINE USES: The requested information will be released on this form to the communications media. It will be used for news publication or
broadcast.
MANDATORY OR VOLUNTARY DISCLOSURE: The release of this information is voluntary. There is no effect on the individual not providing
the requested information.
SECTION I - PATIENT IDENTIFICATION
NAME (Last, First, Middle)
ADDRESS
NAME OF MEDICAL TREATMENT FACILITY
AGE
STATUS
SECTION II - TO BE COMPLETED BY REQUESTOR
I certify that I represent
(Name and Address of Communications Media)
and that medical information on the above identified patient is requested
for news publication or broadcast.
List specific information requested below:
DATE (YYYYMMDD)
SIGNATURE OF PUBLIC AFFAIRS OFFICER
SIGNATURE OF MEDIA REPRESENTATIVE
SECTION III - TO BE COMPLETED BY PATIENT/PARENT/LEGAL REPRESENTATIVE
Authorization Expiration:
Authorization Date (YYYYMMDD):
Date (YYYYMMDD)
Action Completed
I,
, hereby request and authorize the release of the requested
information concerning my illness or injury and hospital treatment (complete when other than patient gives consent-the illness or injury and hospital
treatment of (
) while a patient in the medical treatment facility, to the
above mentioned communications media. I hereby agree to hold the hospital, its physicians, and its staff free and harmless from any, and all liabilities
or ill effecfts which might arise from the publication or broadcast of such information.
I understand that:
a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my medical records are
kept. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or disclosed my protected information on the
basis of this authorization.
b. If I authorize my protected health information to be disclosed to someone who is not required to comply with federal privacy protection regulations,
then such information may be re-disclosed and would no longer be protected.
c. I have a right to inspect and recieve a copy of my own protected health information to be used or disclosed, in accordance with the requirements of
the federal privacy protection regulations found in the Privacy Act and 45 CFR § 164.524.
d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the TRICARE
Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this authorization.
SIGNATURE OF PATIENT/PARENT/GUARDIAN
Relationship to Patient (If applicable)
DATE (YYYYMMDD)
SIGNATURE OF WITNESS
DATE (YYYYMMDD)
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00ES
DA FORM 4876, APR 2010
Page 1 of 2
REQUEST AND RELEASE OF MEDICAL INFORMATION TO COMMUNICATIONS MEDIA
For use of this form see AR 40-66; the proponent agency is the Office of The Surgeon General.
PRIVACY ACT STATEMENT
AUTHORITY: Section 3012, title 10, United States Code.
PRINCIPAL PURPOSE(S): This form provides for patient/parent/guardian consent to release requested personal medical information to news
publication or broadcast.
ROUTINE USES: The requested information will be released on this form to the communications media. It will be used for news publication or
broadcast.
MANDATORY OR VOLUNTARY DISCLOSURE: The release of this information is voluntary. There is no effect on the individual not providing
the requested information.
SECTION I - PATIENT IDENTIFICATION
NAME (Last, First, Middle)
ADDRESS
NAME OF MEDICAL TREATMENT FACILITY
AGE
STATUS
SECTION II - TO BE COMPLETED BY REQUESTOR
I certify that I represent
(Name and Address of Communications Media)
and that medical information on the above identified patient is requested
for news publication or broadcast.
List specific information requested below:
DATE (YYYYMMDD)
SIGNATURE OF PUBLIC AFFAIRS OFFICER
SIGNATURE OF MEDIA REPRESENTATIVE
SECTION III - TO BE COMPLETED BY PATIENT/PARENT/LEGAL REPRESENTATIVE
Authorization Expiration:
Authorization Date (YYYYMMDD):
Date (YYYYMMDD)
Action Completed
I,
, hereby request and authorize the release of the requested
information concerning my illness or injury and hospital treatment (complete when other than patient gives consent-the illness or injury and hospital
treatment of (
) while a patient in the medical treatment facility, to the
above mentioned communications media. I hereby agree to hold the hospital, its physicians, and its staff free and harmless from any, and all liabilities
or ill effecfts which might arise from the publication or broadcast of such information.
I understand that:
a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my medical records are
kept. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or disclosed my protected information on the
basis of this authorization.
b. If I authorize my protected health information to be disclosed to someone who is not required to comply with federal privacy protection regulations,
then such information may be re-disclosed and would no longer be protected.
c. I have a right to inspect and recieve a copy of my own protected health information to be used or disclosed, in accordance with the requirements of
the federal privacy protection regulations found in the Privacy Act and 45 CFR § 164.524.
d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the TRICARE
Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this authorization.
SIGNATURE OF PATIENT/PARENT/GUARDIAN
Relationship to Patient (If applicable)
DATE (YYYYMMDD)
SIGNATURE OF WITNESS
DATE (YYYYMMDD)
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00ES
DA FORM 4876, APR 2010
Page 1 of 2
SECTION IV - TO BE COMPLETED BY ATTENDING PHYSICIAN
Information as requested and authorized is hereby furnished:
DATE (YYYYMMDD)
SIGNATURE OF ATTENDING PHYSICIAN
SECTION V - TO BE COMPLETED BY PATIENT AND ADMINISTRATION DIVISION
Section I through IV have been reviewed and is
Approved
Disapproved for release
DATE (YYYYMMDD)
SIGNATURE OF CHIEF, PATIENT ADMINISTRATION DIVISION (or designated representative)
Upon completion of this form, a copy will be placed in the patient's medical record and a copy will be returned to the Public Affairs Officer for release of
the requested information to the media representative.
APD LC v1.00ES
DA FORM 4876, APR 2010
Page 2 of 2

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