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

whom administrative responsibility has been assumed regardless of the circumstances under which the injury or illness
was incurred.
(1) The section titled “For Local Use” will be used to record the accident information of how, when, and where the
injury occurred.
(2) The DA Form 2985 will be forwarded to the RJA within 3 working days after the day of admission for
screening and determination of a potential medical affirmative claim. The RJA will return the form to the MTF
promptly with one of the following notations: “No Medical Affirmative Claim ” or “Possible Medical Affirmative
Claim.” A claim form (DA Form 2631) will be requested, when required, by the RJA.
(3) If it has been determined that a possible medical affirmative claim exists, the notation: “Medical Affirmative
Claim-Public Law 87-693 and 10 USC 1095” will be entered in item 29 of DA Form 3647 (Inpatient Treatment
Record Cover Sheet) (or automated equivalent) upon its completion. If the DA Form 3647 has been completed prior to
the determination that a possible medical affirmative claim exists, a corrected form will be prepared. DA Form 3647-1
(Inpatient Treatment Record Cover Sheet (for Plate Imprinting)) can be used to transfer diagnoses and procedures to
the CHCS worksheet. DA Form 3647 (4-part set) is available on the APD Web site (www.apd.army.mil). DA Form
3647 (4-part continuous set) will be distributed through normal channels. DA Form 3647-1 is available on the APD
Web site.
(4) The notated admission record (DA Form 2985) will become a permanent part of the clinical record.
c. Outpatient care. MTFs and RJAs will establish local procedures to ensure the RJA is appropriately notified
regarding potentially recoverable outpatient treatment. See paragraph 13-2 regarding identification of recoverable
outpatient treatment. Claim forms and copies of pertinent medical documentation will be provided to the RJA.
13–4. Absent sick active duty personnel
a. The RJA notification procedure described in paragraph 13-3 will be followed for absent sick AD Soldiers treated
for an injury or illness incurred due to a potentially recoverable incident.
b. Unless the determination has been made by the RJA that no medical affirmative claim exists, the responsible
MTF will obtain and provide the RJA with copies of documents supporting the cost and provision of health care
services to absent sick AD Soldiers. This includes, but is not limited to, copies of bills or appropriate vouchers
supporting the payments and medical records or other medical documentation.
13–5. Medical records
a. Requests for medical records/information pertinent to patients treated for a potentially recoverable incident are
subject to the following:
(1) MTFs must route all requests pertaining to potentially recoverable incidents and/or replies to such requests for
medical records or medical information from all sources, other than those related to TPCP pre-certification and
utilization review, through the RJA for release. These include but are not limited to requests from patients, attorneys,
and insurance companies.
(2) Excuse from work requests are often received for patients treated for an injury or illness incurred as a result of
an on-the-job or other recoverable incident. These requests must be reviewed carefully to ensure potentially recoverable
treatment is identified and the RJA is appropriately notified. The RJA is responsible for determining whether a
patient’s treatment represents a recoverable claim.
b. A copy of DA Form 3647 (or automated equivalent) and SF 502, if available, will accompany the claim form
submitted to the RJA. If the narrative summary is not available when the claim form is forwarded to the RJA, it will be
forwarded immediately upon completion.
c. Copies of pertinent inpatient medical records or other documentation will be provided to the RJA upon request.
d. MTFs will provide copies of applicable outpatient records, ambulatory surgery records, or other supporting
documentation, such as clinic encounter forms, physical therapy records, etc., to the RJA with the completed claim
form.
13–6. Medical claim forms
a. Transfer patient. For all cases except those for which the RJA has determined that no medical affirmative claim
exists, the MTF will prepare and forward to the RJA a transfer claim form (DA Form 2631) within 3 working days
after the day of transfer or movement of the patient.
b. Filing of form. A copy of each claim form (DA Form 2631 or its substitute (para 13-1f)), submitted to the RJA,
will become a permanent part of the clinical record.
c. DA Form 2631. (See para 13-1f for an explanation of substituting the UB-04 for this form.) Completion of the
form is self-explanatory except for the following items:
(1) Military source care.
(a) In item 6, Disposition or Status of Patient, if the patient has been released from the MTF, enter the date and type
of disposition. If transferred or moved from the MTF, enter the MTF to which dispositioned. If currently on the rolls of
the MTF, enter status (that is, occupying a bed, on leave, AWOL, subsisting elsewhere, or TDY).
AR 40–400 27 January 2010/RAR 15 September 2011
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