RIGHT SIDE OF FOLDER (Continued)
Form Title and Notes
Medical Record--Request for Administration of Anesthesia and
for Performance of Operations and Other Procedures.
Medical Record--Allergen Extract Prescription--New and Refill.
DA Form 5007-R.
Record of Hyposensitization.
Other SF 500 series forms in numerical sequence.
DD Form 741
DD Form 771
DD Form 2215
DD Form 2216
Hearing Conservation Data. Reports or certificates prepared by
neuropsychiatric consultation services or psychiatrists.
Correspondence on hearing aids. Documents and
correspondence on flying status. That is, restrictions, removal of
restrictions, suspensions, and termination of suspensions (see
AR 600-105). Other medical and administrative documents
important enough to keep on file. This includes care provided in
civilian treatment facilities, correspondence on release of
medical information, statements instead of physical examinations
for the promotion of officers and warrant officers, etc.
DA Form 4465
ADAPCP Client Intake Record with Privacy Act Statement.
File any other authorized alcohol and drug forms here.
*DA Form 4410-R
Disclosure Accounting Record (to be included if DD Form 722
is used as the folder instead of the DA Form 3444-series).
*DD Form 2005
Privacy Act Statement--Health Care Records (to be included if
DD Form 722 is used as the folder instead of the DA Form 3444
-series (see AR 40-2, para 1-6c).
*This form must be included in all health records.
Table 2-1. Forms and documents of the Health Record (concluded).