(7) Enter the member's current organization, when applicable, but use a soft
pencil. The member's organization is subject to change.
(8) DD Form 2005 (Privacy Act Statement - Health Care Records) is
preprinted on the right inside cover of DA Form 3444 Series. It provides advice required
by The Privacy Act of 1974. Ensure that the person reads and signs the preprinted DD
(9) DA Form 4410-R (Disclosure Accounting Record) is preprinted on the left
inside cover of DA Form 3444 but does not require entries at this time. It is used to
record the nature and purpose of medical record disclosure. Upon receipt of a signed
request from the patient, information contained in HRECs may be released to insurance
companies, civilian physicians, attorneys, etc. Some instances of when information
may be released with the patient's signature or knowledge are stated in Item 3 of DD
Form 2005 (see fig 2-1). The importance of proper documentation of disclosure of
information cannot be overstated.
A completed DA Form 3444 is illustrated in figure 2-1.
Figure 2-1. DA Form 3444 used as a Health Record (continued).