Patient Administration - Army Publishing Directorate - U.S. Army

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SF 502 Medical Record-Narrative Summary (Clinical Resume) SF 523 Clinical Record-Authorization for Autopsy SF 523A Medical Record-Disposition of Body SF 1034 and 1034A Public Voucher for Purchases and Services Other than Personal SF 1080 Voucher for Transfer Between Appropriations and/or Funds CMS 1450 (UB–04) (corrected title) Uniform Bill (This form can be obtained from the Standard Register Company, Forms Division, through local civilian business forms suppliers.) VA Form 10–10EZ Application for Health Benefits (Available at http://www.va.gov/vaforms/search_action.asp.) VA Form 10–10M Medical Certificate 100 AR 40–400 27 January 2010/RAR 15 September 2011
Appendix B Persons authorized care at Army military treatment facilities B–1. Quick reference Table B–1, below, serves as a quick reference for personnel who admit and bill patients at Army MTFs. (Notes and definitions not defined in the glossary are at the end of the appendix.) B–2. Where to find updated charges Updated charges can be found in the MSA table of CHCS, figure B-1, which identifies abbreviations used in the table. Table B–1 Persons authorized care at Army military treatment facilities Paragraph Class of Patient Patient Category Charges Collect Report required Hearing aids, prostheses, Codes for central reim- spectacles, or orthopedic footbursement wear Section I. Members of the Uniformed Services 3-1 and 3-2 Members of the USA, USN, USAF, and USMC (including IETs) serving on AD or ADT. 3-1 Cadets and midshipmen of USA, USN, and USAF Academies. 3-2 RC members not on AD medicalexaminations. 3-3 SROTC members with LD conditions incurred during required field training. A11, N11, F11, M11 Inpatient Outpatient or Sub- or Immusistence nization Subsistenceonly. A14, N14, F14 Subsistenceonly. A22, A23, N22, N23, M22, M23 A21, N21, F21, M21 Subsistenceonly. Subsistenceonly. None while on AD. FRR for RC membersaftertrainingperiod ends unless care is specificallyauthorized. Enlisted Army, SF1080; all others DD139 None. From the FAO at the appropriate Service academy for USA and USAF cadets. From the Chief of Naval Personnel, Department of the Navy for midshipmen at the USNA. None. Locally from the individual. None. Yes for AD members. Yes for RC members subject to limitations in paragraph 3- 2. None. Yes. None. No. None. From RPA. DD Form 139 Yes, subject to limitations in paragraph 3-3. AR 40–400 27 January 2010/RAR 15 September 2011 101
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Army Regulation 40-400 Medical Serv
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Headquarters Department of the Army
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Contents—Continued Department of
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Contents—Continued Autopsy author
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Contents—Continued Chapter 13 Inj
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Chapter 1 Introduction 1-1. Purpose
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nonemergent specialty care. The Pri
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(1) If not prohibited under the law
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Table 2-3 Supplemental care payment
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a. Treatment during and after duty.
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the camp commander or the MTF comma
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e provided an employee paid from ap
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(2) The Health Insurance Portabilit
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(n) Section 13. Signature of the MT
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discharged or transferred. When an
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encompasses the geographic area whe
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(3) Peace Corps applicants. (a) Exc
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the emergency. The patient or respo
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physicians, dentists, nurses (pract
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. Each Uniformed Service secretary
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3-61. Treatment of former military
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Figure 3-2. Sample format memorandu
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4-3. Comfort items for patients a.
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Kingdom, and the United States The
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f. The MTF commander who starts act
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(1) Attempt to arrange transfer to
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(3) Patients who are being or have
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personal decisions will be assisted
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authorities, to the sponsor or NOK.
Page 59 and 60: (2) Enabling care (EC). AD patients
Page 61 and 62: patients in absent sick status, cha
Page 63 and 64: date the packet is mailed to the PE
Page 65 and 66: (4) A complete, current report of m
Page 67 and 68: Table 7-1 Distribution of medical b
Page 69 and 70: d. Instructions for the preparation
Page 71 and 72: . After approval by the Service rev
Page 73 and 74: . Soldiers who are in initial entry
Page 75 and 76: a. The following information will b
Page 77 and 78: c. Civilians interned by the Army.
Page 79 and 80: a. Members of the Army, RC, and app
Page 81 and 82: medical documents by submitting DD
Page 83 and 84: 11-10. Audit and review The MSA is
Page 85 and 86: lost. The MSA must have the interna
Page 87 and 88: Figure 11-2. Sample memorandum form
Page 89 and 90: Chapter 12 Patients’ Trust Fund 1
Page 91 and 92: (2) Deposits and requests for check
Page 93 and 94: whom administrative responsibility
Page 95 and 96: 13-7. Concurrent medical affirmativ
Page 97 and 98: (4) Establish a process whereby all
Page 99 and 100: (1) Receive and open mail including
Page 101 and 102: d. Patient administrators of deploy
Page 103 and 104: AR 215-1 (not cited) Military Moral
Page 105 and 106: AR 36-2 Audit Services in the Depar
Page 107 and 108: VASRD Veteran’s Administration Sc
Page 109: DA Form 5009 Medical Record-Release
Page 113 and 114: Table B-1 Persons authorized care a
Page 127 and 128: (3) Is there a procedure in place t
Page 129 and 130: Glossary Section I Abbreviations AA
Page 131 and 132: EIN employee identification number
Page 133 and 134: MPRJ military personnel records jac
Page 135 and 136: REP 63 Reserve Enlistment Program o
Page 137 and 138: VA Veterans Affairs VARO Veterans A
Page 139 and 140: Disability separation Temporary or
Page 141 and 142: Maximum hospital benefit That point
Page 143 and 144: standard CHAMPUS cost shares apply.
Page 145 and 146: Convalescent leave, 5-1 Cosmetic su
Page 147 and 148: Civilian participants in Army-spons
Page 149 and 150: For assignment to WTU, 8-3 Outside
Page 151 and 152: Special consideration of USFHP bene
Page 153 and 154: Social Security, table 2-1, 3-21, 3
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Patient Administration - Army Publishing Directorate - U.S. Army

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