Fillable Dd Form 2138 - Request For Transfer Of Outpatient Record printable pdf download

Dd Form 2138 - Request For Transfer Of Outpatient Record

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REQUEST FOR TRANSFER OF OUTPATIENT RECORD

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974 - Use Blanket PAS - DD FORM 2005)

(This form may be used only when requesting records from US Military Medical and Dental facilities)

INSTRUCTIONS TO SPONSOR

I. REQUEST THAT THE OUTPATIENT RECORD(S)

Complete Sections I and II of form. Deliver form

OF INDIVIDUAL(S) LISTED BELOW BE TRANS-

to U.S. Military outpatient clinic which will next

FERRED TO THIS TREATMENT FACILITY

provide outpatient care for the dependents.

PRINT NAME (Last, First, Middle Initial) AND

II.

SPONSOR INFORMATION

RELATIONSHIP TO SPONSOR (Family member prefix

GRADE NAME (Last, First, Middle Initial)

code). EMBOSSED PATIENT’S CARD MAY BE

USED.

DEPT

SSAN

III.

REQUESTING FACILITY

FROM: (Complete mailing address of requesting facility)

REQUESTER (Signature, grade, title)

DATE

DD Form 2138, JAN 78

REPLACES AF FORM 275, MAR 71, WHICH IS OBSOLETE.