DA Form 4254 PDF: Request for Private Medical Information – DA Form 4254, officially titled Request for Private Medical Information, is a key U.S. Army form used to request protected health information (PHI) from military treatment facilities (MTFs). It ensures compliance with privacy regulations while allowing authorized personnel to access necessary medical records.
This guide explains the form’s purpose, proper use, completion steps, and download options for service members, dependents, and authorized personnel in the United States.
What Is DA Form 4254?
DA Form 4254 is a Department of the Army form for requesting private medical information held by military medical treatment facilities. The current version dates to February 2003 (DA FORM 4254, FEB 2003), and it supersedes the older DA FORM 4254-R.
The form is referenced in AR 40-66 (Medical Record Administration and Health Care Documentation) and managed by the Office of The Surgeon General (OTSG). It helps maintain HIPAA-compliant processes for releasing protected health information within the military health system.
Purpose of DA Form 4254
The primary purpose of DA Form 4254 is to formally request and authorize the release of private medical information, such as records from hospitalizations, clinic visits, diagnoses, or treatments at an MTF.
It is commonly used by:
- Military personnel and their authorized representatives
- Command authorities and investigating officers
- Legal or administrative staff needing records for official purposes
- Healthcare operations requiring specific patient information
The form ensures that only the minimum necessary information is released and that requests include proper justification.
When to Use DA Form 4254?
Use DA Form 4254 when requesting PHI from a military medical treatment facility for official purposes without patient consent in certain authorized scenarios. Examples include command-directed needs, investigations, or specific healthcare operations.
Note: For patient-authorized releases or personal requests, other forms like DD Form 2870 may be more appropriate. For VA claims involving private (non-military) providers, VA Form 21-4142 is typically used.
How to Fill Out DA Form 4254 Step by Step?
Filling out DA Form 4254 is straightforward. Complete it accurately to avoid delays or disapproval.
- Block 1: Date — Enter the date in YYYYMMDD format.
- Block 2: Patient’s Name and SSN — Provide the full name and Social Security Number of the individual whose records are requested.
- Block 3: Medical Treatment Facility — Specify the name and location of the MTF where the care was provided.
- Block 4: Reason for Request — Clearly explain the official reason (e.g., medical evaluation, investigation, command need). Be specific.
- Block 5: Private Medical Information Sought — Detail the exact information needed, including dates of visits, hospitalizations, or specific diagnoses if known.
- Block 6: Requestor’s Name, Title, Organization and SSN — Provide your details as the requester.
The lower section is for MTF use only:
- Approval/Disapproval decision
- Summary of information released
- Signature of the approving official and date
Always attach supporting documentation, such as appointment orders or proof of need-to-know, when required.
Download DA Form 4254 PDF
Official Download Link:
DA Form 4254 PDF (Army Publishing Directorate)
This is the fillable official version. Save it to your device, complete it digitally or by hand, and submit according to your MTF’s procedures (often via fax, mail, or in-person).
Key Tips for Successful Submission
- Provide as much specific detail as possible in Blocks 4 and 5 to speed processing.
- Include proof of identity and official need-to-know.
- Follow up with the relevant MTF’s Patient Administration Division if you do not receive a response.
- Retain a copy of the completed form for your records.
Related Forms and Regulations
- DD Form 2870: Authorization for Disclosure of Medical or Dental Information
- AR 40-66: Governs medical record administration and use of this form
- DOD 6025.18-R: Privacy of Individually Identifiable Health Information
For veterans seeking records for VA claims, coordinate with your VA representative and use appropriate VA forms for non-military providers.
Conclusion
DA Form 4254 is an essential tool for properly requesting private medical information within the U.S. Army and Military Health System. Understanding its purpose and completing it correctly helps ensure compliance, protects privacy, and facilitates timely access to needed records.
For the most current information, always refer to official Army publications and your local medical treatment facility. Download the form directly from the Army Publishing Directorate and consult with medical records personnel if you have questions about your specific situation.