DA FORM 4254 Fillable – Army Pubs 4254 PDF

DAFORMFILLABLE.COM | DA FORM 4254 Fillable – Army Pubs 4254 PDFDA FORM 4254, titled Request For Private Medical Information, is a crucial document used within the military to request personal medical information. The form, first issued on 02/01/2003, is managed by the TSG (The Surgeon General) and remains active and in use. This article provides an in-depth look at the purpose, usage, and important aspects of DA FORM 4254.

DA FORM 4254 – Request For Private Medical Information

Form Number DA Form 4254
Form Title Request For Private Medical Information
Form Date 02/01/2003
Form Proponent TSG

Overview of DA FORM 4254

Purpose of DA FORM 4254

The primary purpose of DA FORM 4254 is to facilitate the request and release of private medical information. This form is essential in ensuring that medical information is obtained and shared securely and appropriately within authorized channels. The information gathered through this form is often used for medical evaluations, treatment planning, and other health-related decisions.

Key Information on DA FORM 4254

  • Pub/Form Number: DA FORM 4254
  • Pub/Form Date: 02/01/2003
  • Pub/Form Title: Request For Private Medical Information
  • Pub/Form Proponent: TSG (The Surgeon General)
  • Pub/Form Status: Active
  • Security Classification: Unclassified
  • Distribution Restriction Code: A (Approved for public release; distribution is unlimited)
  • Pub/Form IDN: 990001
  • Pub/Form PIN: 080718

Prescribing Directive

DA FORM 4254 is prescribed by AR 40-66, which outlines the policies and procedures for handling medical information within the military. Compliance with AR 40-66 ensures that all requests for private medical information adhere to the highest standards of confidentiality and security.

Detailed Breakdown of DA FORM 4254

Sections of DA FORM 4254

DA FORM 4254 is divided into several sections, each designed to capture specific information necessary for processing the request. These sections include:

Personal Information

This section collects the personal details of the individual whose medical information is being requested. It includes fields for name, rank, Social Security Number (SSN), and contact information.

Medical Information Requested

Here, the requester specifies the type of medical information needed. This can range from general health records to specific medical evaluations or treatment histories.

Purpose of Request

In this section, the requester must provide a clear and legitimate reason for needing the medical information. This ensures that the request is justified and within the scope of authorized use.

Authorization and Signature

The form must be signed by the individual whose medical information is being requested or by a legally authorized representative. This signature authorizes the release of the specified information and ensures that the request complies with legal and regulatory requirements.

Importance of DA FORM 4254 in Military Operations

Ensuring Confidentiality and Security

One of the most critical aspects of DA FORM 4254 is its role in maintaining the confidentiality and security of private medical information. By using this standardized form, the military ensures that all requests for medical information are handled with the utmost care and in accordance with established protocols.

Facilitating Medical Care

Access to accurate and complete medical information is essential for providing effective medical care. DA FORM 4254 enables healthcare providers to obtain the information they need to make informed decisions about a patient’s care, ultimately improving health outcomes.

Compliance with Regulations

The use of DA FORM 4254 ensures compliance with AR 40-66 and other relevant regulations governing the handling of medical information. This compliance is vital for maintaining the integrity and accountability of the military healthcare system.


DA FORM 4254 – Request For Private Medical Information is a fundamental tool within the military for requesting and handling private medical information. By adhering to the guidelines and requirements outlined in this form, the military ensures that medical information is obtained and shared securely, confidentially, and in accordance with regulatory standards. Understanding the purpose and proper use of DA FORM 4254 is essential for anyone involved in the management or provision of military healthcare services.

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