What Is This Army Confidentiality Form?
The Army Limits of Confidentiality PDF is a one-page form given to military healthcare patients before starting mental health, substance abuse, or behavioral health treatment at a U.S. Army military treatment facility (MTF). It explains specific situations in which personal health information may be shared without prior written consent under Army regulation AR 40-66.
Who Receives This Form?
Any service member, dependent, or retiree seeking behavioral health treatment, substance abuse counseling, or psychiatric evaluation services at an Army MTF is given this form. Providers present it to ensure patients understand their confidentiality rights and acknowledge receipt before their first appointment.
Key Limits of Confidentiality
The form describes exceptions to patient confidentiality, including situations involving risk of harm, abuse cases, legal proceedings, fitness-for-duty evaluations, and care coordination. These pages balance protecting patient privacy with U.S. Army safety and readiness requirements under HIPAA and the Privacy Act.
Related Army PDF Forms
FormsPal also hosts other Army and privacy PDF forms, including the Army Certificate DA Form 87, the Soldiers Privacy Act Statement, and the HIPAA Confidentiality Form.