DA Form 5009: Release Against Medical Advice (PDF) – U.S. Army form used in military treatment facilities (MTFs) when a patient chooses to leave against the recommendations of their healthcare providers.
This official document protects the facility, staff, and government by documenting that the patient (or their representative) has been informed of the risks and still insists on leaving. It is prescribed for use under AR 40-68, with the Office of The Surgeon General as the proponent agency.
Download the latest DA Form 5009 here: https://armypubs.army.mil/pub/eforms/DR_a/pdf/A5009.pdf
What Is DA Form 5009?
DA Form 5009, titled Medical Record – Release Against Medical Advice, formally records a patient’s decision to depart a military hospital or clinic contrary to medical advice.
It serves as a legal and medical record that the patient understands the potential dangers, has been advised on recommended follow-up care, and voluntarily releases the facility, its staff, and the Federal Government from liability for any adverse outcomes resulting from leaving prematurely.
This form is part of the broader DoD health record management system and helps maintain proper documentation in compliance with regulations like those outlined in DHA-PM 6025.02.
When Is DA Form 5009 Used?
Military medical facilities use DA Form 5009 whenever a patient (service member, dependent, or other authorized beneficiary) decides to leave against medical advice (AMA).
Common scenarios include:
- Inpatient deciding to depart before completing treatment or observation.
- Outpatient or emergency room patient refusing recommended admission, tests, or procedures.
- Situations involving a patient’s legal representative making the decision for an incapacitated individual.
Providers must thoroughly explain risks and alternatives before presenting the form. The form helps document informed consent (or refusal) and protects against future claims.
Key Sections of DA Form 5009
The form has two main statements: one for the patient and one for a representative (if applicable).
Patient Statement Includes:
- Certification of leaving at own insistence against advice of the named facility and attending physician(s).
- Acknowledgment of understood potential medical risks (space provided to list specific risks explained).
- Understanding of recommended follow-up actions.
- Release of liability for the hospital/clinic, staff, and Federal Government.
Representative Statement (if patient cannot sign):
- Details the representative’s relationship to the patient.
- Similar acknowledgments and release of liability.
Additional fields capture:
- Patient ID plate or printed name, SSN, address, and daytime phone.
- Signatures: Patient/Representative, Physician/Designee, and Witness.
- Department/Ward/Clinic, Date (YYYYMMDD), and Time.
Step-by-Step: How to Fill Out DA Form 5009?
- Patient/Representative Information — Complete identifying details at the top or bottom.
- Facility and Advice — Enter the name of the Medical Treatment Facility.
- Risks and Follow-Up — The physician/designee clearly documents specific potential dangers and recommended follow-up care in the provided spaces.
- Signatures — The patient (or representative) signs and dates, confirming understanding. A physician/designee and witness also sign.
- Filing — Place the completed form in the patient’s medical record per Army and DoD health record procedures.
Tip: Always use the most current version from the official Army Publications site to ensure compliance.
Importance of Signing a Release Against Medical Advice
Signing DA Form 5009 demonstrates that the patient received proper counseling about risks. It reduces legal exposure for military healthcare providers and the government while promoting patient autonomy and informed decision-making.
Note: Leaving AMA can affect continuity of care, potential TRICARE coverage implications in some cases, and future medical or administrative actions. Patients should carefully consider the documented risks before signing.
DA Form 5009 vs. Civilian AMA Forms
While similar to civilian “Against Medical Advice” discharge forms, DA Form 5009 is specifically tailored for U.S. Army and DoD facilities. It references Federal Government liability release and integrates directly into military health records. Other branches may use comparable procedures, but this form is the Army standard.
Where to Get and Submit DA Form 5009?
- Official Download — Army Publishing Directorate.
- Availability — At all Army medical treatment facilities.
- Related Forms — Often used alongside privacy forms like DD Form 2870 (Authorization for Disclosure of Medical or Dental Information).
For questions about completing or filing the form, contact the medical records department at your local military treatment facility.
This article provides general information based on official U.S. Army sources and is not legal or medical advice. Always consult qualified healthcare providers and legal professionals for specific situations.