Da Form 5018 R PDF Details

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.

QuestionAnswer
Form NameDa Form 5018 R
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesda form 5018fillable, form 5018 r, da 5018 r fillable, 5018 r form

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ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION

For use of this form, see AR 600-85; the proponent agency is DCSPER.

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 6-9b(4)(b) and 6-10e(3), AR 600-85)

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 5018-R, NOV 1981

USAPA V1.00