DA Form 4159: Request for Medical Care (PDF Guide) – Military personnel, reservists, and eligible family members in the United States sometimes require medical care at federal facilities beyond standard Department of Defense (DoD) Military Treatment Facilities (MTFs). DA Form 4159 formalizes these requests under AR 40-400.
Download the official DA Form 4159 here: https://armypubs.army.mil/pub/eforms/DR_a/pdf/A4159.pdf
What Is DA Form 4159?
DA Form 4159 is the official U.S. Army form titled “Request for Medical Care in a Federal Medical Treatment Facility Outside Department of Defense.” It was last revised in May 2009 by the Office of the Surgeon General.
Service members use this form to request authorization for treatment at non-DoD federal medical facilities, such as certain Veterans Affairs (VA) facilities or other federal health resources, when DoD facilities cannot provide the needed care or in specific eligibility scenarios.
The form is prepared in triplicate and references AR 40-400 for patient administration policies.
Purpose of DA Form 4159
The primary purpose is to request medical care or services in a federal facility outside the DoD system. It ensures proper administrative tracking, notification to the nearest Army MTF for inpatient admissions, and record-keeping.
Key uses include:
- Supporting reservists (USAR, ANG, AROTC) on inactive duty training or specific active duty training.
- Documenting injuries or illnesses occurring during training.
- Facilitating care coordination when standard DoD MTFs are unavailable or inappropriate.
- Ensuring the Army maintains oversight of medical records and responsibility.
This form helps bridge care between DoD and other federal systems while maintaining accountability.
Who Should Use DA Form 4159?
Eligible users typically include:
- Active duty Army personnel in specific circumstances.
- USAR (U.S. Army Reserve), ANG (Army National Guard), and AROTC members on inactive duty training.
- ANG members on active duty training.
- Certain dependents or other authorized beneficiaries when care outside DoD MTFs is required.
It applies primarily within the United States for situations where federal (non-DoD) care is appropriate, such as specialized services or geographic needs. Commanders, medical officers, or unit personnel usually initiate or review it.
How to Fill Out DA Form 4159: Step-by-Step Guide?
Complete the form accurately to avoid delays. Here are the main sections:
- Date and Addresses: Enter the date, “TO” (destination facility with ZIP), and “FROM” (requester/unit with ZIP).
- Patient Information (Blocks 1-4): Patient’s name, grade, organization, and station.
- Patient’s Status (Blocks 5-8): Location of training/incident, duty status (e.g., active duty for training, inactive duty, pass, leave), and membership (USAR, ANG, etc.).
- Treatment Details (Block 9): Nature of treatment or service required, including known diagnosis.
- Reason for Request (Block 10): Especially detailed for reservists—include date of occurrence and description of events for injuries/diseases.
- Disposition Instructions (Block 11): Instructions after treatment completion.
- Signature: Typed name, grade, and signature of the authorizing official.
Tip: If admitted as an inpatient, the receiving facility must notify the closest Army MTF immediately for administrative responsibility.
When and Why to Submit DA Form 4159?
Submit this form when:
- Required care is best provided at a non-DoD federal facility (e.g., VA or other federal sites with agreements).
- DoD MTF capacity is limited or the specialty is unavailable.
- Specific training-related injuries for reserve components need documentation and authorization.
It supports continuity of care, proper billing/charging where applicable, and compliance with Army medical administration rules. Always consult your unit medical personnel or commander for current procedures.
Key Benefits and Considerations for U.S. Service Members
- Streamlined Authorization: Formalizes requests for federal care outside normal DoD channels.
- Record Keeping: Ensures Army medical records are updated with diagnosis, treatment, and disposition details.
- Eligibility Focus: Particularly useful for National Guard and Reserve members during training periods.
- Compliance: Aligns with AR 40-400 patient administration policies.
Note: Policies can evolve with TRICARE, VA partnerships, or DoD directives. Verify with your local medical command or military treatment facility for the most current guidance.
Service members and units should retain copies and follow up on approvals and notifications.
Download and Resources
Official Download: DA Form 4159 PDF from Army Publishing Directorate.
For related information, refer to AR 40-400 (Patient Administration) and consult your chain of command or military health advisors.
This form remains an essential tool for ensuring eligible military personnel receive timely federal medical care while maintaining proper DoD oversight. If you need assistance with this form, contact your unit’s medical section or nearest Army medical facility.