Permission To Release Medical Treatment Facility Records

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FOR OFFICIAL USE ONLY
DEPARTMENT OF THE AIR FORCE
48TH FIGHTER WING (USAFE)
DATE: _______________
MEMORANDUM FOR RECORD
FROM: Subject of IRC
SUBJECT:
Permission to Release Medical Treatment Facility Records
Name of Requesting Agency:
48 FSS
POC at Requesting Agency:
Ricky J. Woodard
Duty Phone:
DSN 314-226-2434
1. In accordance with DoD Instruction 1402.05 and AF Instruction 34-144 all personnel working with or near
children under 18 years of age must have an IRC. The following individual is being considered for either
employment or a volunteer position in a DoD-sanctioned activity:
a. APPLICANT NAME: ________________________________________
b. APPLICANT SSN: __________________________________________
c. APPLICANT DATE OF BIRTH: _______________________________
d. PROSPECTIVE POSITION: ___________________________________
e. NAME OF MILITARY SPONSOR: ______________________________________
f. SSN OF MILITARY SPONSOR: _______________________________________
g. CURRENT ADDRESS (PSC #, Box #, and Zip Code): ______________________________________________
2. The Privacy Act protects the information in this letter. DoD personnel must conduct this IRC. Information
contained herein should be protected as sensitive medical information.
NOTE: 48 MDOS/SGOW Mental Health Flight will conduct a review of Medical Facility Records of AHLTA,
Mental Health, ADAPT, and Family Advocacy Program Records, to include an AF Central Registry Check:
- The 48 MDOS/SGOW review will be documented on the AF Form 2583
- Results will be noted on the AF Form 2583 section 30: cleared, no record, or unfavorable
3. The applicant and the applicant’s sponsor acknowledge that both of the social security numbers provided above
will be submitted for an AF Central Registry check to verify the applicant has no documented history of perpetrating
child maltreatment.
_______________________________________
___________________________________________
Signature of Applicant (date)
Signature of Sponsor (date)
"The information
herein is
For
Official Use Only
(FOUO)
which must
be
protected
under
the Freedom of
Information Act of 1966 and
Privacy
Act
of
1974,
as
amended.
Unauthorized disclosure
or misuse
of this
PERSONAL
INFORMATION
may
result
in
criminal
and/or
civil
penalties"
Submit Application

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