DA Form 4254. Request for Private Medical Information

Form DA Form 4254 is a request form used by the Department of the Army to obtain private medical information from individuals. The purpose of this form is gather necessary medical information for various reasons, such as medical evaluations, disability determinations, or fitness-for-duty assessments.

The form consists of sections where individuals need to provide their personal details, such as name, social security number, and contact information. Additionally, there are sections to specify the purpose of the request, the type of medical information needed, and any specific instructions or authorizations required.

Important fields on this form include the individual's consent release their medical information, as well any limitations or restrictions on the release of certain sensitive information. It is crucial to ensure that all information provided is accurate and complete to facilitate proper evaluation and decision-making processes.

Parties involved in the completion of this form include the individual whose medical information is being requested, the authorized personnel within the Department of the Army responsible for processing the request, and any healthcare providers or institutions holding the requested medical records.

Application Example: An example scenario where the DA Form 4254 would be used is when a soldier is undergoing a medical evaluation for a potential disability claim. In this case, the soldier would need to complete the form, providing their personal information, specifying the purpose of the request (disability evaluation), and authorizing the release of their medical records from relevant healthcare providers. The completed form would then be submitted the appropriate Army personnel responsible for processing the requestp>