Da 4700 Form – Fill Out and Use This PDF

Da 4700 Form PDF Details

The DA 4700 Form, officially titled the Medical Record-Supplemental Medical Data form, is the standard Army document used to evaluate Exceptional Family Member (EFM) respite care eligibility under the Exceptional Family Member Program (EFMP). Medical providers complete this document to determine whether an EFM qualifies for additional support services. A completed DA 4700 form is required before the installation EFMP Manager can approve respite care.

Who must complete the DA 4700 form

A qualified medical provider, such as a physician, nurse practitioner, or other licensed clinician, must complete the form on behalf of the Exceptional Family Member. The provider assesses the EFM against specific eligibility criteria and certifies the findings with a signature. The form cannot be self-reported by the family. Once complete, the family submits a copy to the installation EFMP Manager for review and approval.

Respite care eligibility criteria

The medical provider must verify that the EFM meets at least one of the following conditions to qualify for respite care under FMWRC guidelines:

• Lacks age-appropriate self-help skills due to a physical or developmental disability
• Experiences severe continuous seizure activity requiring constant supervision
• Requires tube feeding, tracheotomy care, or apnea monitoring
• Needs assistance with daily living activities due to neurological impairment
• Has a life-threatening condition causing frequent hospitalizations
• Requires constant supervision due to ongoing safety concerns

Eligibility is reviewed every two years or when the family moves to a new duty station. An updated care eligibility assessment is submitted at each review to document the EFM's current medical information and ongoing care needs.

Completing and submitting the form

The provider documents the EFM's diagnosis, the type of care required, and supporting clinical information. The form covers assistance with daily activities, specialized medical care such as apnea monitoring or tube feeding, and conditions requiring continuous oversight. After the medical provider signs the form, the family submits the document to the installation EFMP Manager. The manager uses the information to coordinate respite care services and maintain continuity of care across duty stations.

Related Army forms

Other Army forms commonly used alongside the DA 4700 include the DA Form 7666 parental consent form, the DA Form 4856 developmental counseling form, and the EFMP Consumer Application for equipment replacement requests. For general Army counseling and records, see also Army OER Support Form DA 67-9-1.