expense who were hospitalized for an injury. A copy of the most recent SF 502, Narrative
Summary, should be forwarded with each DA Form 2631-R. However, forwarding of the
DA Form 2631-R must not be delayed for completion of the SF 502. If the SF 502 is not
available, when DA Form 2631-R is prepared, the DA Form 2631-R should be forwarded
ahead.
e. DA Form 2631-R, Medical Care--Third Party Liability Notification. Initiation
of this form is determined by: transfer/movement of a patient or by a request of the RJA.
Within three working days after the day of transfer or movement of a patient in all cases
except those for whom the RJA has determined that no third party liability exists, DA Form
2631-R, must be prepared and forwarded to the RJA. The RJA will request this form when
it is required by the RJA. For the most part, this form is self-explanatory; however, several
items may need explanation. You may find it helpful to refer to figure 2-2 as we discuss
these items.
(1) Item 5: Check the box "transfer" if the form is initiated because of the
transfer/movement of a patient for whom the RJA has determined that no medical
affirmative claim exists. Check the box "required by the RJA" for those initiated in
response to a request from the RJA.
(2) Item 11 (Military Hospital Care): This item should be completed according
to instructions in AR 40-16, para 5b. Item 11d: This entry should be the appropriate
inpatient rate as stated in Appendix H, AR 27-40. Item 11f: Enter any amount paid locally
by the patient, or on behalf of the patient, by anyone other than an agency of the Federal
Government.
(3) Item 12 (Military Outpatient Care): This entry should be completed
according to instructions in AR 40-16, para 5c.
(4) Item 13 (Civilian Source Care): Item 13 also includes other nonmilitary
source care. The RJA must complete this item on active duty members who were moved
to a Federal nonuniformed service facility to await separation or disability retirement. For
all other types of civilian source care, entries should be made according to AR 40-16, para
5d.
f. DA Form 3154, MSA Invoices and Receipt: Upon request from the RJA, the
reporting facility must prepare a consolidated statement of charges. This is accomplished
on DA Form 3154 (see figure 2-3). When the Army has made payments to civilian
sources, the voucher(s) must be attached to DA Form 3154 and the amount paid entered
in the remarks section of the form together with this notation: "Payment for care from
civilian sources--see attached voucher(s)." When it is apparent from the patient's record
that care has been obtained at the Army's expense and information about the value or cost
of this care is not in the record, appropriate action must be taken to obtain the necessary
data about such care for inclusion in the consolidated statement.
MD0755
2-5
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