Figure 1-6. Sample wrist identification band.
1-11. OTHER FORMS
a. DA Form 3696 (Patient's Deposit Record). The deposit record is initiated by
imprinting with the nine-line plate (admitting plate). An original and a copy are prepared
and signed by the custodian (under funds or valuables for deposit) and by the patient
(upper-right block with the word "not" deleted) if the patient wishes to deposit funds and
valuables. The original is sent to the Patients' Trust Fund (covered in another lesson) and
the copy is retained y the patient. If the patient has no deposits, only an original is
prepared for the custodian and is signed by the patient in the upper-right corner to indicate
that no deposit is to be made. The admitting clerk should inform the patient that the
hospital will not assume liability or responsibility for loss of funds and valuables which are
retained in the patient's possession. When the patient wishes to make a deposit, the
patient takes both copies of DA Form 3696 to the Patients' Trust Fund. The Patients' Trust
Fund personnel and receipt for funds and valuables by signing the DA Form 3696. The
patient is given one signed copy. The deposit record has spaces for withdrawals and
deposits during the patient's stay in the hospital. See figure 1-7.