DA Form 5018-R at a glance
What it is: DA FORM 5018-R is the ADAPCP Client's Consent Statement for Release of Treatment Information.
Who signs: The form has SIGNATURE OF CLIENT with DATE, NAME OF WITNESS (Type or print) with SIGNATURE and DATE, and NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE (Type or print) with DATE and SIGNATURE.
A filled-in DA Form 5018-R example: a client consents to a release of treatment information
How to fill out DA Form 5018-R, box by box
Section A - Consent
Enter the client's full name after I, and fill in this day of.
After do hereby voluntarily consent to the release of the following information by, enter the 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, enter the name on the line after research to, the one the release of the following information is to.
Enter the purpose after for the purpose of, and the extent or nature of information to be disclosed after namely.
Section B - Expiration/Revocation
SECTION B - EXPIRATION/REVOCATION. Check applicable paragraph.
Box 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.
Box 2, for disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b(4)(b) and 6-10e(3), AR 600-85: I understand that this consent automatically expires 60 days from today's date or when my present criminal justice system status changes to, enter the status on the line after changes to.
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.
Section C - Approval authority for release of information
Other than the MEDCEN/MEDDAC Commander, approval authority for release of information may be delegated to the Program Physician or the Clinical Director.
Section C: In my judgment, the release of an evaluation of the present or past status of, enter the client's name before (client's name), in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her.
More rules for DA Form 5018-R
For use of this form, see AR 600-85; the proponent agency is DCS, G-1.
Sources
[1] DA Form 5018-R (NOV 1981), ADAPCP Client's Consent Statement for Release of Treatment Information, Department of the Army (the Official source link on this page).