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Military Medical Record Request Form
1. Personal Information Section: Contains requestor's full name, Social Security Number, date of birth, current address, phone number, and email address
2. Service Information Section: Details of military service including branch, service dates, service number/ID, rank, and unit information
3. Records Request Details: Specific information about which medical records are being requested, including date ranges and facility locations
4. Privacy Act Statement: Mandatory statement regarding the Privacy Act of 1974 and how the information will be used
5. Authorization Section: Legal authorization and signature section for release of medical records
1. Third Party Authorization: Section to be completed when someone other than the service member is requesting records, including legal representative information
2. Urgent Request Declaration: Section for indicating and justifying expedited processing due to medical necessity or legal requirements
3. Special Handling Instructions: Section for specific delivery or processing instructions when standard handling is not sufficient
1. Required Documentation Checklist: List of required supporting documents including ID verification requirements
2. Types of Available Medical Records: Comprehensive list of different types of medical records that can be requested
3. Instructions for Completion: Detailed guidelines for filling out the form correctly and submitting required documentation
Authors
Service Member
Veteran
Military Health Record
Electronic Health Record (EHR)
Authorized Representative
Power of Attorney
DD Form 214
Military Treatment Facility (MTF)
TRICARE
Custodian of Records
Release Authorization
Next of Kin
Disclosure
Health Care Provider
Service Branch
Active Duty
Medical Documentation
Personal Representative
Military Service Number
Records Request
Verification of Identity
Treatment Period
Medical History
Confidential Information
Identity Verification
Authorization for Release
Privacy Protection
Records Specification
Purpose of Request
Data Protection
Confidentiality
Third-Party Access
Record Delivery Method
Processing Time
Fee Structure
Documentation Requirements
Certification
Restrictions on Use
Verification of Service
Medical Facility Information
Records Timeline
Emergency Request
Legal Authority
Information Accuracy
Record Format
Signature Requirements
Expiration of Authorization
Amendment Rights
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