DA Form 4359: Authorization for Psychiatric Service Treatment

DA Form 4359: Authorization for Psychiatric Service Treatment – DA Form 4359, titled Authorization for Psychiatric Service Treatment, is an official U.S. Army form used to document a service member’s (or authorized patient’s) voluntary request and consent for hospitalization and treatment in a Psychiatry Service treatment unit.

It ensures informed consent, explains patient rights and unit policies, and complies with Army regulations for mental health care documentation. The current version is dated FEB 2003 (DA FORM 4359, FEB 2003), and it remains active.

This form is required for inpatient psychiatric admissions in Army medical treatment facilities (MTFs) and supports proper medical record administration.

Download the official DA Form 4359 here: https://armypubs.army.mil/pub/eforms/DR_a/ARN43098-DA_FORM_4359-001-EFILE-2.pdf

Purpose of DA Form 4359

The primary purpose of DA Form 4359 is to record formal authorization and consent for psychiatric hospitalization and treatment. Key elements include:

  • Patient acknowledgment that admission is needed for study and treatment.
  • Understanding of unit policies, including potential requirements to remain on the ward or with staff.
  • No guarantees on treatment outcomes.
  • Right to request discharge (not a legal commitment), with procedures following local and federal laws.
  • Consent for photographs, videotapes, or observation by medical trainees for educational or research purposes (with privacy protections).

It is governed by AR 40-66 (Medical Record Administration and Health Care Documentation), with the Office of The Surgeon General as the proponent agency.

Who Needs DA Form 4359?

This form applies primarily to:

  • Active-duty Army service members.
  • Other eligible beneficiaries (e.g., dependents) requiring psychiatric inpatient care in Army facilities.
  • Situations involving voluntary admission to a Psychiatry Service treatment unit.

Military healthcare providers, admitting physicians, and patients (or authorized representatives) use it during the admission process.

How to Fill Out DA Form 4359 (Step-by-Step)?

  1. Patient Identification: Enter the patient’s full name, sex, year of birth, relationship to sponsor, component/status, department/service. Include sponsor’s details (name, rank/grade, SSN/ID, organization).
  2. Statement of Authorization: Review and understand all points (1–4) regarding consent, policies, discharge rights, and media/observation consent.
  3. Signatures:
    • Patient (or authorized person) signs and dates (YYYYMMDD).
    • Witness (preferably spouse or relative) signs and dates.
    • Admitting physician (or designated representative) signs and dates.

Tips for Completion:

  • Use mechanical imprint, typing, or clear printing.
  • Ensure all sections are complete to avoid delays.
  • The form becomes part of the patient’s official medical record.

Key Provisions and Patient Rights

  • Voluntary Nature: Hospitalization is not involuntary commitment; patients can request discharge.
  • Informed Consent: Patients receive explanations of policies and procedures.
  • Privacy Protections: Photos/videos exclude names and are limited to medical study/research.
  • No Outcome Guarantees: Treatment results cannot be assured.

These provisions align with broader DoD and Army policies on mental health care and patient rights.

Where to Get and Submit DA Form 4359?

  • Official Source: Download directly from the Army Publishing Directorate (APD) at the link above.
  • Submission: Completed forms are filed in the patient’s inpatient medical record per AR 40-66 guidelines.
  • Additional resources: Army medical treatment facilities, unit medical personnel, or official Army forms portals.

Note: Always use the most current version from armypubs.army.mil for compliance.

Importance in Army Mental Health Care

DA Form 4359 plays a critical role in:

  • Ensuring ethical and legal standards for psychiatric care.
  • Supporting seamless documentation in military health records.
  • Facilitating access to necessary mental health treatment for service members.
  • Maintaining compliance with federal statutes and Army regulations on consent and records.

In the U.S. Army, prioritizing mental health is essential for readiness and well-being. Proper use of this form helps protect both patients and providers while enabling effective treatment.

For questions about completing or using DA Form 4359, consult your unit medical staff, Military Treatment Facility (MTF) administrators, or refer to AR 40-66. Service members experiencing mental health concerns should reach out to their chain of command, behavioral health providers, or resources like Military OneSource.

This article is for informational purposes only and does not constitute legal or medical advice. Always refer to official Army publications and consult qualified professionals.