c. Unofficial Requests. Information may be released to a third party requestor,
such as an insurance company or civilian health care facility, if the patient has provided
specific written consent. Other persons requesting medical information must include an
authorization for release of information. A copy of the authorization and the information
released should be filed in the patient's medical record. Whenever possible, DA Form
5006-R, Medical Record - Authorization for Disclosure of Information (see figure 2-2) will
be used. In all instances, authorization must:
(1) be submitted in writing.
(2) be signed and dated by the patient (a parent or legal guardian may sign if
the patient is a minor or mentally incompetent; nearest known relative or executor may
sign if the patient has died).
(3) state the period of hospitalization or treatment for which information is
(4) name the individual or organization to whom the information is to be
(5) state the purpose for which the information may be used.
d. Release to the Patient. If a patient requests information from his medical record
or copies of documents in it, it will be provided. Access to the information will be denied,
however, if a physician or dentist judges that it could adversely affect the patient's physical
or mental health. When this happens, the patient may name another physician or dentist to
whom the record may be released.
e. Release to Family Members. Commanders or chiefs of medical treatment
facilities will release information on the condition of sick or injured patients to the patient's
(1) Adult patients must provide written consent for the release of medical
records or medical information to other persons.
(2) If the patient is mentally incompetent (adjudged insane) or is a minor, the
record or information may be released to the parents or legal representative.