DA Form 3904. Public Voucher for Medical Examination

The DA Form 3904, known as the "Public Voucher for Medical Examination," is a form utilized by the Department of Army for reimbursement of medical examination expenses incurred by individuals authorized entitlements for medical services provided outside military treatment facilities.

This form consists of various sections which capture relevant information. The initial section includes personal details of the individual receiving the medical examination, such as their name, rank, unit, and social security number. The second section lists the details of the medical examination, including the date of the examination, the purpose, and the amount expended. The third section is for certification and approval, where authorized personnel confirm the validity and necessity of the medical examination.

When filling out the DA Form 3904, it is important to ensure accuracy in providing personal and medical examination details. Care should be taken to correctly list the purpose of the examination and verify that the expenses are appropriately presented. It is crucial to provide necessary supporting documentation, such as receipts or invoices, to substantiate the expenses claimed.

An example of when this form may be used is when military personnel or their dependents require medical examinations outside of military treatment facilities, such as specialized tests or consultations with civilian specialists. The form would be filled out and submitted along with the necessary documentation to request reimbursement for the incurred expenses. This form helps to facilitate the reimbursement process and ensure compliance with regulations governing medical entitlements.