Loading...Download DA Form 8004, also known as Army Substance Abuse Program (ASAP) Outpatient Medical Records Privacy Act Information. This form is supplied to the patient to ensure that he/she understands their rights under the privacy act. This form is not a consent form to release or use health care information about you. Some information is included below. It would be best to download the form to get all of the information included.
Step 1. – Read Block one. This section addresses what your privacy rights are about and the sections that refer to them. Read 1. and 2. a. through e.
“AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN). Title V, Public Law 92-129; section 501, 42 USC section 290dd.”
Step 2. – Read sections 3.a. and b. and 4.a. and b. These areas address what can be released and how it is legal to do so.
“Active Army Soldiers. Release of any information from this record is subject to the restrictions of 21 USC 1175 as amended by 88 Stat 137; 42 USC 4582 amended by 88 Stat 131 chapter 1, title 42, Code of Federal Regulations. Under these statutes and regulations, disclosure of information that would identify the patient as an abuser of alcohol or other drugs is authorized within the Armed Forces or to those components of the Veterans Administration furnishing health care to veterans. AR 600-85 further limits disclosure within the Armed Forces to those individuals having an official need to know (for example, the physician or the patient’s unit commander).”
Step 3. Once you’ve read the information entirely, and should you understand and agree, fill in the following:
- 5. Signature of Patient or Sponsor
- 6. SSN of Member or Sponsor
- 7. Date yyyy/mmdd