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

Form DA 4876 is used to request and release medical information to communications media. This form serves as a means to control the release of medical information to the media for specific purposes.

The form consists of sections where the specific details of the request are recorded, including the name of the media organization, the purpose of the request, and the specific medical information to be released. It includes information about the patient or individual whose medical information is being requested and any necessary authorizations for the release of the information. Additionally, the form may include sections for recording any restrictions or conditions on the release of the medical information.

Important fields in this form include accurate documentation of the request and release of medical information, clear indication of the purpose and specific information to be released, and proper recording of any necessary authorizations or restrictions. Accurate completion of this form is crucial to ensure the confidentiality and privacy of patients' medical information while meeting the legal and ethical requirements for releasing such information to the media.

Application Example: A media organization contacts a military hospital to request information about a patient's medical condition for a news story. The hospital uses Form DA 4876 to document the specific information to be released, the purpose of the request, and any necessary authorizations obtained from the patient or their legal representative. The completed form is reviewed by the hospital's legal department before releasing the requested medical information to the media. By doing so, the Army can ensure that patients' privacy rights are protected, and the release of medical information is in compliance with applicable laws and regulations.

Individuals filling out this form should consider any additional guidelines or procedures provided by the Army's policies on the release of medical information to the media.

Related Forms: There may not be direct alternatives to Form DA 4876, as it serves as a specialized form for the release of medical information to the media in the Army. However, there might be other forms related to medical information release and authorization used in similar healthcare and media settings.