DA Form 4665: Patients’ Trust Fund Daily Summary (PDF)

DA Form 4665: Patients’ Trust Fund Daily Summary (PDF) – U.S. Army form used in military medical treatment facilities (MTFs) to track daily financial transactions for patients’ personal funds.

This article provides comprehensive information for Army personnel, medical administrators, patient advocates, and others involved in military healthcare finance. It covers purpose, usage, completion guidelines, and official resources based on AR 40-400 and current Army publications.

What Is DA Form 4665?

DA Form 4665, titled “Patients’ Trust Fund – Daily Summary Record,” is an official Department of the Army form (March 2000 edition). It serves as the daily ledger for summarizing all deposits, withdrawals, and balances in the Patients’ Trust Fund (PTF) at Army MTFs.

The form is prescribed for use under AR 40-400 (Patient Administration), with the Office of The Surgeon General as the proponent agency. It helps maintain accurate, auditable records of patients’ personal money and valuables held in trust during their stay.

Note: The form is produced in electronic media and available as a fillable PDF. The previous December 1977 edition is obsolete.

Purpose of the Patients’ Trust Fund and DA Form 4665

The Patients’ Trust Fund protects and manages personal funds and valuables for patients in Army medical facilities. These funds are not government property but are held in a custodial capacity.

DA Form 4665 provides a daily summary that ensures:

  • Accurate tracking of beginning balances, receipts (deposits in cash or checks), withdrawals, and ending balances.
  • Proper separation of cash and check transactions.
  • Daily recapitulation for accountability and auditing.
  • Compliance with internal controls for safeguarding patient assets.

This supports broader patient administration under AR 40-400, Chapter 12, which details administration, responsibilities, safeguarding, procedures upon admission, and audits of the trust fund.

Key Features and Layout of DA Form 4665

The two-sided form includes:

  • Header: Name of MTF, page number, date.
  • Patient Details: Individual patient names and register numbers (often linked to DA Form 3696 Patient’s Deposit Record).
  • Transaction Columns: Receipts (Cash/Checks) and Withdrawals (Cash/Checks).
  • Recapitulation Section: Beginning balance, total receipts, total withdrawals, total cash on hand, change fund variation, and daily activity summary.
  • Certification: Typed name, grade, signature, and date of the authorized official (typically finance or patient administration personnel).

The reverse side continues transaction details and recapitulation for multiple entries.

How to Fill Out DA Form 4665 (Step-by-Step Guidance)?

While specific block-by-block instructions are integrated into the form and AR 40-400 procedures, general steps include:

  1. Enter MTF Name and Date at the top.
  2. List Patient Transactions: Record each patient’s name, register number, receipts (cash/checks), and withdrawals (cash/checks).
  3. Calculate Daily Totals: Sum receipts and withdrawals separately for cash and checks.
  4. Complete Recapitulation:
    • Beginning balance.
    • Total receipts.
    • Total withdrawals.
    • Ending balance (Total cash on hand).
    • Note any change fund variation.
  5. Certification: The authorized official signs and dates the form.

Related Forms:

  • DA Form 3696 (Patient’s Deposit Record) — Used for initial deposits.
  • Other supporting documents for admissions and audits per AR 40-400.

Accuracy is critical for audits and internal controls. Finance officers or designated patient administration staff typically complete it.

Who Uses DA Form 4665?

  • Patient Administration Branches in Army MTFs.
  • Finance Officers responsible for trust fund management.
  • Medical Treatment Facility Commanders and custodians.
  • Army National Guard and U.S. Army Reserve medical units during relevant duty.

It applies to active duty, retirees, family members, and other eligible patients whose funds are held in trust.

Download Official DA Form 4665 PDF

Official Download:
DA Form 4665 PDF (U.S. Army Publishing Directorate).

Additional resources:

  • Army Publishing Directorate (armypubs.army.mil)
  • AR 40-400 (Patient Administration) — July 2014 version details Chapter 12 on Patients’ Trust Fund.

Best Practices and Compliance

  • Perform regular audits as required by AR 40-400.
  • Safeguard funds and valuables per regulation.
  • Ensure proper transfer of custody when custodians change.
  • Maintain separation of patient funds from government accounts.
  • Use electronic versions where available for better record-keeping.

Compliance protects patients and avoids discrepancies in accountability.

Conclusion

DA Form 4665 is essential for transparent and secure management of the Patients’ Trust Fund in U.S. Army healthcare settings. Proper use ensures patients’ personal finances remain protected during medical care. Always refer to the latest AR 40-400 and official Army publications for the most current guidance.

For questions specific to your MTF, consult your Patient Administration Division or the Office of The Surgeon General.

This information is for educational and reference purposes, based on publicly available U.S. Army sources as of 2026. Official policies may be updated; verify with current Army directives.