3-9.
DA FORM 2173, STATEMENT OF MEDICAL EXAMINATION AND DUTY
STATUS
Procedures to complete DA Form 2173.
Block
Entry
Commander
THRU
Patient's present unit and zip code
Commander
TO
Address of patient's next higher command
Commander
FROM
Address of patient's medical treatment facility
NOTE:
The following information will be taken from DA Form 2895, Admissions and
Coding Information.
1
Name of patient examined
2
Patient's SSN
3
Patient's grade
4
Patient's organization and station
5
a.
Accident date
Example: 20 Jan 8X
b.
Place of accident
Example: Ft. Splendid, TX
NOTE:
Section I--to be completed by attending physician or hospital patient
administrator. You are responsible for reviewing or typing in the information
provided by the physician or patient administrator.
6
Mark "X" in the appropriate box "Individual was: Outpatient,
Admitted, Dead on Arrival"
7
Mark "X" in the appropriate box "Civilian or Military," and
name of MTF
8
Enter hour, day, month, year of admission
Example: 0830, 21 June 8X
9
Enter hour, day, month, year of examination
MD0755
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