Da Form 8004 For use of this form see AR 40 66 the proponent agency is the OTSG DA FORM 8004 FEB 2003 USAPA V1 00ES 5 Signature of Patient or Sponsor 6 SSN of Member or Sponsor 7 Date YYYYMMDD This form is not a consent form to release or use health care information about you 1 AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY
A The DA Form 8004 contains privacy act information such as the purpose for collecting the information and the authority for collecting it Q Who is required to fill out the DA Form 8004 A Individuals receiving outpatient treatment in the Army Substance Abuse Program ASAP are required to fill out the DA Form 8004 Fillable Form DA 8004 ARMY SUSTANCE ABUSE PROGRAM ASAP OUTPATIENT MEDICAL RECORDS PRIVACY ACT INFORMATION FILL ONLINE EMAIL SHARE ANNOTATE FILL ONLINE FILL ONLINE Contents What is DA 8004 How to fill out DA 8004 FAQs about DA 8004 FILL ONLINE Related Forms DA 7633 DA 7636
Da Form 8004
Da Form 8004
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https://www.armyreal.com/forms/pdf/A8004.pdf
For use of this form see AR 40 66 the proponent agency is the OTSG DA FORM 8004 FEB 2003 USAPA V1 00ES 5 Signature of Patient or Sponsor 6 SSN of Member or Sponsor 7 Date YYYYMMDD This form is not a consent form to release or use health care information about you 1 AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY
https://www.templateroller.com/template/1726396/da-form-8004-army-sustance-abuse-program-asap-outpatient-medical-records-privacy-act-information.html
A The DA Form 8004 contains privacy act information such as the purpose for collecting the information and the authority for collecting it Q Who is required to fill out the DA Form 8004 A Individuals receiving outpatient treatment in the Army Substance Abuse Program ASAP are required to fill out the DA Form 8004
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DA FORM 8004 Fillable Army Pubs 8004 PDF Download The DA FORM 8004 officially titled Army Substance Abuse Program ASAP Outpatient Medical Records Skip to content DA Forms 2024 Menu Menu This form is supplied to the patient to ensure that he she understands their rights under the privacy act This form is not a consent form to release or use health care information about you Some information is included below It would be best to download the form to get all of the information included Step 1 Read Block one This section
The form consists of sections that explain the purpose and use of medical records privacy act information and participant acknowledgment It may also include DA Form 8004 DA Form 8003 is an official document used by the United States Department of Defense DoD in accordance with AR 40 66 regulations The purpose of this form is to facilitate a command referral for a comprehensive Substance Use Disorder SUD assessment of a service member The assessment aims to determine if the individual meets the criteria for mandatory enrollment in a
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At the heart of this crucial initiative lies DA Form 8004 a document that holds within it not just medical records but also a delicate balance between confidentiality and accountability Evaluation counseling required by AR 600 85 Be advised that your failure to sign a release DA Form 8004 seek counseling and complete Army approved State certified treatment may result in your discharge IAW AR 135 178
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