DA FORM 3696 Fillable – Army Pubs 3696 PDF

DAFORMFILLABLE.COM | DA FORM 3696 Fillable – Army Pubs 3696 PDF – DA FORM 3696, commonly referred to as the Patient’s Deposit Record, is a crucial document used within the United States Army Medical Department. This form is designed to ensure accurate and secure handling of patient deposits during medical care. In this article, we will explore the key features, uses, and procedural importance of DA FORM 3696.

DA FORM 3696 – Patient`S Deposit Record

Form Number DA Form 3696
Form Title Patient`S Deposit Record
Form Date 12/01/1977
Form Proponent TSG

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.

Key Details of DA FORM 3696

  • Pub/Form Number: DA FORM 3696
  • Pub/Form Date: 12/01/1977
  • Pub/Form Title: Patient’s Deposit Record
  • Pub/Form Proponent: The Surgeon General (TSG)
  • Pub/Form Status: ACTIVE
  • Prescribed Forms/Prescribing Directive: AR 40-400
  • Security Classification: UNCLASSIFIED
  • Distribution Restriction Code: A (Approved for public release; distribution is unlimited)

These details highlight the form’s longstanding use and its significance in handling patients’ personal items and monetary deposits.

Purpose and Use of DA FORM 3696

The primary purpose of DA FORM 3696 is to record and manage deposits made by patients in military hospitals or medical facilities. This form is essential for:

  • Ensuring Transparency: By recording each deposit, the form helps maintain clear and transparent financial records.
  • Protecting Patient Valuables: It acts as a safeguard for patients’ valuables, providing a systematic way to keep track of personal items.
  • Enhancing Accountability: Medical staff are held accountable for the deposits, minimizing the risk of loss or misplacement.

How DA FORM 3696 is Used

When a patient enters a military medical facility and decides to deposit valuables or money for safekeeping, the medical staff will fill out DA FORM 3696. The form includes:

  • Patient Identification: Details about the patient including name, rank, and service number.
  • Item Description: Detailed description of each item or amount of money deposited.
  • Signature Fields: Signatures from both the patient and the custodian of the deposit, enhancing mutual accountability.

Compliance and Regulations

DA FORM 3696 is prescribed by AR 40-400, which deals with patient administration in Army medical facilities. The form also adheres to the Privacy Act as indicated by the footnote ’14-REQUIRES PRIVACY ACT STATEMENT (AR 340-21)’, ensuring that all personal data is handled with confidentiality.

Security and Privacy

Given its classification as UNCLASSIFIED and its approval for public release (Distribution Code A), DA FORM 3696 is accessible for training and reference. However, when filled out, it contains sensitive personal information, and strict privacy measures are applied to protect this data.


DA FORM 3696 – Patient’s Deposit Record plays a vital role in managing the financial and personal valuables of patients within Army medical facilities. Its careful design and structured use help ensure that patient deposits are handled securely and with high transparency. Understanding and using this form correctly is essential for medical personnel to maintain trust and accountability in their service to patients.

For further information or to view the form, you can refer to the official website of the United States Army Publishing Directorate (APD). This will provide you with additional resources and guidance on the implementation of DA FORM 3696.

By familiarizing yourself with DA FORM 3696, you enhance your professional capabilities and contribute to the efficient and secure operation of medical services in the military sector.

DA FORM 3696 Fillable – Army Pubs 3696 PDF DOWNLOAD

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