(use hospital letterhead)
SUBJECT: Release from Hospitalization
______________________________________________________
Name, Rank, & Serial No. , Br of Svc (Act Army, USAR, NG)
TO:
(Name & Address of Unit)
1.
Patient was admitted _________________________________________
Date, Time
discharged ________________________________________
Date, Time
Nature of discharge:
Total days of hospitalization
_______________
Number of subsistence charge days
_______________
Number of authorized absence days
_______________
Pass days
_______________
Leave days
_______________
Leave
Date/time
Date/time
Departure
of return
_________
________
_________
________
2. You should have already submitted a DA Form 4187 with a absent hospital entry based on our
n
previous notification of hospital admission. This automatically suspended our separate rations payments to
the service member during the period of hospitalization. In order to make the necessary adjustments to the
member's pay request, you must now submit a DA Form 4187 with all the information contained in para 1
above.
3. Questions concerning entitlements and collections for periods of hospitalization of enlisted members
should be addressed to your local Finance and Accounting Office. Further guidance is contained in JUMPS
Army LOI 84-02, dated 5 Dec 83.
FOR THE COMMANDER:
________________________
Name, Rank & Br of Svc
Position
Figure 4-13. Suggested format for letter used to prepare DA Form 4187.
MD0752
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