LEFT SIDE OF FODER
Form Number
Form Title and Notes
DA Form 5571
Master Problem List. (Filing in ITR is optional)
DA Form 3947
Medical Evaluation Board Proceedings.
(See AR 40-3).
DA Form 3349
Physical Profile. (See AR-501).
DA Form 3894
Hospital Report of Death. (See AR 40-2).
DA Form 2631-R
Medical Care - Third Party Liability Notification.
(See AR 40-16).
DA Form 2984
Very Seriously Ill/Seriously Ill/Special Category
Patient Report. (See AR 40-2).
DA Form 4876-R
Request and Release of Medical Information to
DA Form 5006-R
Medical Record - Authorization for Disclosure of
Information.
SF 544
Clinical Record - Statement of Patient's Treatment
DA Form 5009-R
Medical Record - Release Against Medical Advice.
RIGHT SIDE OF FOLDER
Form Number
Form Title and Notes
DA Form 4515
(See AR 50-5).
DA Form 3647
Inpatient Treatment Record Cover Sheet.(all versions).
SF 502
Clinical Record - Narrative Summary.
SF 503
Clinical Record - Autopsy Protocol.
SF 539
Medical Record - Abbreviated Medical Record.
SF 504
Clinical Record - History - Parts II.
SF 505
Clinical Record - History - Parts II and III.
SF 506
Clinical Record - Physical Examination.
SF 535
Clinical Record - Newborn.
SF 509
Medical Record - Doctor's Progress Notes.
SF 558
Medical Record - Emergency Care Treatment.
DA Form 3888
Nursing Care Plan (See AR 40-407).
DA Form 3888-1
Medical Record - Nursing Assessment and Care Plan
Continuation (See AR 40-407).
SF 510
Nursing Notes.
SF 511
Medical Record - Vital Signs Record (See AR 40-407).
SF 512
Clinical Record - Plotting Chart.
Table 1-1. Filing sequence for documents in ITR folder (continued).
MD0753
1-31