The Department of Defense Form 5018, Request for Authorization to Release Information from Personnel Records, is a document used by military personnel and their families to request access to their records. The form can be used to obtain copies of military service records, medical records, and other information from the individual's file. The form must be filled out and submitted to the appropriate agency in order for the request to be processed. If you are a military service member or family member and would like to request information from your personnel record, download a copy of the Department of Defense Form 5018 and submit it according to the instructions on the form. Your request will be processed as quickly as possible.
Question | Answer |
---|---|
Form Name | Da Form 5018 R |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | da form 5018fillable, form 5018 r, da 5018 r fillable, 5018 r form |
ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION
For use of this form, see AR
SECTION A - CONSENT
I, |
, this |
day of |
19 |
, |
(client's full name)
do hereby voluntarily consent to the release of the following information by
(name of installation ADAPCP)
pertaining to my identity, diagnosis, prognosis, or treatment from any Army record maintained in connection with
alcohol or other drug abuse education, training, treatment, rehabilitatiton, or research to
for the purpose of
namely,
(extent or nature of information to be disclosed)
SECTION B - EXPIRATION/REVOCATION
(Check applicable paragraph)
1. I understand that this consent automatically expires when the above disclosure action has been taken in
reliance thereon and that, except to the extent that such action has been taken, I can revoke this consent at any time.
- Or -
(For disclosure to civilian criminal justice officials under the provisions of paragraphs
2.
I understand that this consent automatically expires 60 days from today's date or when my present
criminal justice system status changes to
Further, I understand that if my release from confinement, probation, or parole is conditioned upon my participation in the ADAPCP, I cannot revoke this consent until there has been a formal and effective termination or revocation of my release from such confinement, probation, or parole.
SIGNATURE OF CLIENT
DATE
NAME OF WITNESS (Type or print)
SIGNATURE
DATE
SECTION C - APPROVAL AUTHORITY FOR RELEASE OF INFORMATION
NOTE: Other than the MEDCEN/MEDDAC Commander, approval authority for release of information may be delegated to the Program Physician or the Clinical Director.
In my judgment, the release of an evaluation of the present or past status of
(client's name)
in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her.
NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE (Type or print)
DATE
SIGNATURE
DA FORM
USAPA V1.00