Da Form 3696 DA FORM 3696 DEC 77 REPLACESEDITIONOF1AUG76 WHICHMAYBEUSED USAPAV1 01 FUNDS VALUABLESRECEIVEDINFULL Patient s or witness s signature and date Created Date
DA Form 3696 Patient s Deposit Record This form is prepared in duplicate at the time a patient initially wishes to deposit his funds or valuables usually at the time of admission to the hospital 1 The top of the form see figure 5 2 is used to enter the patient s identification including the patient s register number Home Medical Reference and Training Manuals DA Form 3696 Patient s Deposit Record Patient Accountability Branch Safeguarding Funds and Valuables Patient Accountability Branch The bottom of the form see figure 5 2 is used to list valuables deposited The information entered includes number
Da Form 3696
Da Form 3696
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Figure 1-8. DA Form 3153 (MSA Patient Ledger Card). - Patient Accountability Branch
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https://www.armyreal.com/forms/pdf/A3696.pdf
DA FORM 3696 DEC 77 REPLACESEDITIONOF1AUG76 WHICHMAYBEUSED USAPAV1 01 FUNDS VALUABLESRECEIVEDINFULL Patient s or witness s signature and date Created Date
http://armymedical.tpub.com/md0752/Safeguarding-Funds-and-Valuables-Patient-Accountability-Branch-179.htm
DA Form 3696 Patient s Deposit Record This form is prepared in duplicate at the time a patient initially wishes to deposit his funds or valuables usually at the time of admission to the hospital 1 The top of the form see figure 5 2 is used to enter the patient s identification including the patient s register number
I-19 Complete.pdf - SDDC - U.S. Army
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For use of this form see AR 40 400 the proponent agency is the Office of The Surgeon General I do do not wish to make a deposit at this time NUMBER DESCRIPTION OF VALUABLES VALUABLES Patient s signature or witness s if patient is unable to sign DA FORM 3696 DEC 1977 REPLACES EDITION OF 1 AUG 76 WHICH MAY BE USED APD LC v1 01 Block at the top of DA Form 3696 which is retained by the custodian If the patient wishes to make a deposit the following procedures are followed a The admitting clerk prepares DA Form 3696 in duplicate b The patient takes both copies of DA Form 3696 to the custodian who
What is DA FORM 3696 DA FORM 3696 is titled Patient s Deposit Record It was first issued on December 1 1977 and remains an active form used by the Army s medical personnel The form helps in recording deposits made by patients during their stay in medical facilities ensuring that any money or valuables deposited for safekeeping are properly accounted for Fillable Form DA 3696 PATIENT S DEPOSIT RECORD FILL ONLINE EMAIL SHARE ANNOTATE FILL ONLINE FILL ONLINE Contents What is DA 3696 How to fill out DA 3696 FAQs about DA 3696 FILL ONLINE Related Forms DA 1380 DA 1506 DA 2166 8 NCO Evaluation Report
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A DA Form 3696 is used by patients and staff at military medical treatment facilities Q What information is recorded on DA Form 3696 A DA Form 3696 records the patient s name Social Security Number date of the deposit amount deposited and signature of the person accepting the deposit DA FORM 3696 DEC 1977 armypubs army Get Form Show details PATIENT IS DEPOSIT RECORD For use of this form see AR 40 400 the proponent agency is the Office of The Surgeon General I have been informed that any funds or valuables in my possession while a We are not affiliated with any brand or entity on this form
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Da Form 3696 - For use of this form see AR 40 400 the proponent agency is the Office of The Surgeon General I do do not wish to make a deposit at this time NUMBER DESCRIPTION OF VALUABLES VALUABLES Patient s signature or witness s if patient is unable to sign DA FORM 3696 DEC 1977 REPLACES EDITION OF 1 AUG 76 WHICH MAY BE USED APD LC v1 01