(To mail, address and send through the Base Distribution System)
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REPLACES AF FORM 275, MAR 71, WHICH IS OBSOLETE.
(To mail, address and send through the Base Distribution System)
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REPLACES AF FORM 275, MAR 71, WHICH IS OBSOLETE.
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