DA FORM 4665 Fillable – Army Pubs 4665 PDF

DAFORMFILLABLE.COM | DA FORM 4665 Fillable – Army Pubs 4665 PDFDA FORM 4665, titled Patients` Trust Fund – Daily Summary Record, is an essential document used in various healthcare facilities to maintain accurate records of patient funds. Published on March 1, 2000, this form is actively prescribed under AR 40-400 and is authorized for public release with unlimited distribution. This article aims to provide an informative and educational overview of DA FORM 4665, highlighting its purpose, structure, and the importance of maintaining accurate records.

DA FORM 4665 – Patients` Trust Fund – Daily Summary Record

Form Number DA Form 4665
Form Title Patients` Trust Fund – Daily Summary Record
Form Date 03/01/2000
Form Proponent TSG

Purpose of DA FORM 4665

The primary purpose of DA FORM 4665 is to serve as a daily summary record of transactions involving the Patients` Trust Fund. This fund is crucial in ensuring that patients’ financial transactions are tracked meticulously, providing transparency and accountability. Healthcare facilities use this form to document deposits, withdrawals, and the daily balance of the trust fund, thereby safeguarding the financial interests of patients.

Structure and Content of DA FORM 4665

Header Information

The top section of DA FORM 4665 includes essential header information such as the publication number (DA FORM 4665), the publication date (03/01/2000), and the form title (Patients` Trust Fund – Daily Summary Record). This section also specifies the form’s proponent (TSG) and its status as active.

Transaction Details

The main body of the form is dedicated to recording the transaction details. Each entry typically includes:

  • Date of the transaction
  • Description of the transaction (e.g., deposit, withdrawal)
  • Amount credited or debited
  • Running balance

By maintaining detailed records of each transaction, healthcare facilities can ensure that all financial activities related to the Patients` Trust Fund are accurately documented.

Daily Summary

At the end of each day, the form requires a daily summary of the total deposits, withdrawals, and the ending balance. This summary helps in quickly assessing the financial status of the trust fund at any given time, ensuring that any discrepancies can be promptly identified and addressed.

Importance of Accurate Record-Keeping

Ensuring Accountability

Accurate record-keeping using DA FORM 4665 is crucial for ensuring accountability within healthcare facilities. By meticulously tracking each transaction, healthcare administrators can provide a clear audit trail, which is essential for financial audits and inspections.

Protecting Patients’ Interests

Maintaining precise records helps protect the financial interests of patients. It ensures that their funds are managed responsibly and that there are no unauthorized transactions. This transparency builds trust between patients and the healthcare facility.

Compliance with Regulations

The use of DA FORM 4665 is mandated under AR 40-400, and compliance with this regulation is necessary for the lawful operation of healthcare facilities. Accurate completion of this form ensures that facilities adhere to the prescribed guidelines, avoiding any potential legal issues.

Access and Distribution

DA FORM 4665 is an unclassified document with a distribution restriction code of “A,” indicating that it is approved for public release and distribution is unlimited. This accessibility ensures that all relevant personnel can obtain and utilize the form as needed.


In conclusion, DA FORM 4665 – Patients` Trust Fund – Daily Summary Record plays a vital role in the financial management of patient funds within healthcare facilities. Its structured format ensures comprehensive documentation of transactions, promoting transparency, accountability, and compliance with regulatory requirements. By understanding and effectively using this form, healthcare administrators can better safeguard the financial interests of their patients, thereby enhancing the overall trust and integrity of the facility.

For more detailed information and access to the form, refer to the relevant prescribing directive, AR 40-400.

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