BY ORDER OF THE SECRETARY OF THE AIR FORCE AIR FORCE

BY ORDER OF THE

SECRETARY OF THE AIR FORCE

AIR FORCE MANUAL 41-210

10 SEPTEMBER 2019

Incorporating Change 1, 22 June 2021

Health Services

TRICARE OPERATIONS AND PATIENT

ADMINISTRATION

COMPLIANCE WITH THIS PUBLICATION IS MANDATORY

ACCESSIBILITY: Publications and forms are available on the e-Publishing website at

www.e-Publishing.af.mil for downloading or ordering.

RELEASABILITY: There are no releasability restrictions on this publication.

OPR: AF/SG3/4S

Supersedes: AFI 41-210, 06 June 2012

Certified by: AF/SG3/4

(Maj Gen Robert I. Miller)

Pages: 233

This publication implements Air Force Policy Directive (AFPD) 41-2, Medical Support. It

identifies and defines the requirements, policies, procedures, activities, and minimum expectations

necessary to ensure a successful Air Force Medical Treatment Facility (MTF) TRICARE

Operations and Patient Administration mission. This publication describes how to manage

TRICARE Operations and Patient Administration including determining eligibility for care,

protecting medical information, managing health records, the preparation and disposition of

medical documentation and managing other administrative activities to support patients.

Organizational alignment of these functions may vary among MTFs. This publication applies to

all civilian employees and uniformed members of the Regular Air Force, Air Force Reserve and

Air National Guard who perform TRICARE Operations and Patient Administration. Ensure all

records created as a result of processes prescribed in this publication are maintained in accordance

with Air Force Manual 33-363, Management of Records, and disposed of in accordance with the

Air Force Records Disposition Schedule located in the Air Force Records Information

Management System Records Disposition Schedule. Refer recommended changes and questions

about this publication to Air Force Medical Readiness Agency (AFMRA)/SG3S using the Air

Force Form (AF Form) 847, Recommendation for Change of Publication; route AF Forms 847

from the field through the appropriate functional chain of command. All field publications that

either implement or supplement this publication must be submitted to AFMRA/SG3S for

coordination prior to approval. (T-2). The authorities to waive wing/unit level requirements in

this publication are identified with a Tier (“T-0, T-1, T-2, T-3”) number following the compliance

statement. See AFI 33-360, Publications and Forms Management, for a description of the

authorities associated with the Tier numbers. Submit requests for waivers through the chain of

2  AFMAN41-210  10 SEPTEMBER 2019 
command to the appropriate  Tier  waiver  approval  authority,  or  alternately,  to  the  requestor’s 
commander  for  non-tiered  compliance  items.    The  use  of  the  name  or  mark  of  any  specific 
manufacturer,  commercial  product,  commodity,  or  service  in  this  publication  does not  imply 
endorsement  by  the  Air  Force.    This  manual  requires  the  collection  and/or  maintenance  of 
information protected by Title 5 United States Code Section 552a, Privacy Act of 1974, authorized 
by 10 U.S.C. Chapter 55, Medical and Dental Care, and E.O. 9397 (SSN).  The applicable SORN 
F044 AF SG D, Automated Medical/Dental Record System (August 29, 2003, 68 FR 51998) is 
available at http://dpclo.defense.gov/Privacy/SORNs.aspx. 
SUMMARY OF CHANGES 
This interim change revises AFMAN 41-210 by (1) adding guidance that ensures proper care hand-
off for Reserve Component members who transition from active duty orders to inactive status and 
(2) deleting Section 4K in its entirety.  A margin bar (|) indicates newly revised material. 
 
Chapter 1—OVERVIEW, ROLES AND RESPONSIBILITIES    10 
Section 1A—TRICARE    10 
1.1.  TRICARE Overview. ..............................................................................................  10 
1.2.  TRICARE Operations Overview. ............................................................................  10 
Section 1B—Patient Administration    10 
1.3.  Patient Administration Overview. ...........................................................................  10 
1.4.  Patient Administration Officer, Director and Noncommissioned Officer (NCO). ...  10 
1.5.  HIPAA Privacy Officer. ..........................................................................................  11 
1.6.  Registered Health Information Administrator (RHIA), Registered Health 
Information Technician (RHIT), or Air Force member with equivalent education 
and experience. .......................................................................................................  11 
Section 1C—Medical Coding    11 
1.7.  Medical Coders. ......................................................................................................  11 
1.8.  Air Force Medical Operations Agency (AFMOA) Coding Program Office. ...........  11 
Section 1D—Unit Commanders    12 
1.9.  Unit Commanders. ..................................................................................................  12 
Section 1E—Administrative Assistant to the Secretary of the Air Force (SAF/AA)    12 
1.10.  SAF/AA. .................................................................................................................  12 

AFMAN41-210  10 SEPTEMBER 2019  3 
Chapter 2—HEALTHCARE BENEFITS AND REQUIREMENTS    13 
Section 2A—Healthcare Entitlements for Current and Former Uniformed Services Personnel and 
Foreign Forces Members    13 
2.1.  General Administration of Healthcare Benefits. ......................................................  13 
2.2.  RC Members. ..........................................................................................................  14 
2.3.  Foreign Forces and Their Dependents. ....................................................................  15 
2.4.  Cadets and Midshipmen. .........................................................................................  16 
2.5.  Senior College or University Reserve Officer Training Corps (ROTC) Cadets; 
ROTC Membership Applicants; Uniformed Service Applicants; and Service 
Academy Applicants. ..............................................................................................  16 
2.6.  Medal of Honor Recipients. ....................................................................................  16 
Section 2B—Healthcare for Current and Former Uniformed Service Family Members    16 
2.7.  Un-remarried Former Spouses. ...............................................................................  16 
2.8.  Abused Family Members and Dependents. .............................................................  16 
Section 2C—Healthcare for Eligible Civilians and Special Categories of Beneficiaries and Their 
Family Members    17 
2.9.  Federal Civilian Employees. ...................................................................................  17 
2.10.  Family Members (Dependents) of Federal Civilian Employees. .............................  20 
2.11.  Secretarial Designees. .............................................................................................  20 
2.12.  Members of Uniformed Services Auxiliaries. .........................................................  20 
2.13.  Emergency Care. .....................................................................................................  20 
2.14.  Contractors. .............................................................................................................  20 
2.15.  Family Members (Dependents) of Contractors. ......................................................  20 
2.16.  Expanded Medical Care for Caregivers. ..................................................................  20 
2.17.  Volunteers. ..............................................................................................................  20 
Section 2D—Other Services and Authorizations    21 
2.18.  Additional MTF Requirements ...............................................................................  21 
2.19.  Primary Care Manager Assignments. ......................................................................  24 
2.20.  Sexual Dysfunctions, Inadequacies, or Paraphilic Disorders Treatment..................  26 
Chapter 3—TRICARE OPERATIONS    28 
Section 3A—Access to Care Guidance    28 
3.1.  Access to Care Standards. .......................................................................................  28 

4  AFMAN41-210  10 SEPTEMBER 2019 
Section 3B—Beneficiary Counseling and Assistance Coordinator    28 
3.2.  Beneficiary Counseling and Assistance Coordinator Position and Procedural 
Information. ............................................................................................................  28 
Section 3C—Debt Collection Assistance Officer    28 
3.3.  Debt Collection Assistance Officer Position and Procedural Information. ..............  28 
Section 3D—Service Change Requests    29 
3.4.  Changes in Clinical Services. ..................................................................................  29 
Section 3E—Referral Management Program    33 
3.5.  Referral Management Program. ..............................................................................  33 
Section 3F—Medical In/Out-Processing Program    33 
3.6.  Medical In/Out-Processing Program Overview. ......................................................  33 
3.7.  In-processing Requirements. ...................................................................................  34 
3.8.  Out-processing Requirements. ................................................................................  35 
3.9.  Limited Capability Out-processing. ........................................................................  35 
3.10.  Retirement/Separation Out-processing. ...................................................................  35 
Section 3G—External Resource Sharing Agreements    36 
3.11.  External Resource Sharing Agreement. ...................................................................  36 
Chapter 4—PATIENT ADMINISTRATION FUNCTIONS    37 
Section 4A—Legal Aspects of Protected Health Information (PHI), Release of Information and 
Patient Self-Determination    37 
4.1.  Laws and Provisions Affecting Disclosure of Medical Information. .......................  37 
4.2.  Health Record Custody and Control. .......................................................................  38 
4.3.  General Guidelines on Releasing Medical Information. ..........................................  41 
4.4.  Patient Requests for Copies of Medical Records and Restrictions. .........................  43 
4.5.  Patient Rights (Reference DoDI 6000. ....................................................................  46 
Section 4B—Patient Registration & Multiple Healthcare Eligibility    47 
4.6.  Patient Registration. ................................................................................................  47 
4.7.  Patients with Multiple-Eligibility. ...........................................................................  48 
Section 4C—Patient Travel    49 
4.8.  Patient Accountability for Service Members Traveling to Attend Medical .............  49 
4.9.  Patient Travel Benefit. ............................................................................................  50 
4.10.  Transferring Patients Through the Aeromedical Evacuation System. .....................  53 

AFMAN41-210  10 SEPTEMBER 2019  5 
Section 4D—Quarters Administration    53 
4.11.  Quarters Status. .......................................................................................................  53 
Section 4E—Line of Duty Program Administration    54 
4.12.  Line of Duty Determinations. ..................................................................................  54 
Section 4F—Air Force Secretarial Designee Program Administration    57 
4.13.  Authority. ................................................................................................................  57 
4.14.  U.S. Air Force Secretarial Designee Criteria. ..........................................................  59 
4.15.  Applying for Air Force Designee Status. ................................................................  62 
4.16.  Certain Senior Officials of the United States Government. .....................................  64 
4.17.  Operating the Air Force Secretarial Designee Program Overseas. ..........................  64 
4.18.  Designee Status Used in Claims Against the United States. ....................................  64 
Section 4G—Exceptional Family Member Program    65 
4.19.  Exceptional Family Member Program (EFMP). ......................................................  65 
4.20.  Family Member Relocation Clearance Coordinator (FMRCC). ..............................  65 
Section 4H—Admissions and Dispositions Program Administration    65 
4.21.  Responsibility for Admission Processing. ...............................................................  65 
4.22.  Administrative Admission and Disposition Requirements. .....................................  65 
4.23.  Assuming Administrative Responsibility for Military Members Hospitalized in 
Non-Military Medical Facilities also known as Absent Sick Status. .......................  65 
4.24.  Assuming Administrative Responsibility for AD U. S. Air Force Members 
Hospitalized in DoD Facilities. ...............................................................................  68 
4.25.  Admitting Infants Born Outside the MTF. ..............................................................  68 
4.26.  Admitting Generals/Admirals (Flag Officers), Colonels, and Prominent Persons. ..  68 
4.27.  Reporting Aircraft Accident Admissions. ...............................................................  70 
4.28.  Managing Military Patients Expected To Be Hospitalized Over 90 Days. ..............  71 
4.29.  Deployed Military Members who are Aeromedically Evacuated from 
Contingency Operations to CONUS MTF. .............................................................  71 
4.30.  Readmission of Patients. .........................................................................................  71 
4.31.  Canceling Admissions. ............................................................................................  71 
4.32.  Inpatient Disposition Procedures. ............................................................................  72 
4.33.  Convalescent Leave. ...............................................................................................  75 
Table  4.1.  (Added) Recommendations: Convalescent Leave after Perinatal Loss ...................  75 

AFMAN41-210  10 SEPTEMBER 2019 
34.  Reporting AD Soldiers, Sailors, and Marines Hospitalized in Civilian or Non-
Military Medical Facilities. .....................................................................................  77 
Section 4I—Casualty Reporting Program Administration    78 
35.  Reporting Patients in Casualty Status. .....................................................................  78 
36.  Assigning Responsibility.........................................................................................  78 
37.  Requesting and Arranging Travel for Legally Authorized Representative under 
the Emergency Family Member Travel Program. ...................................................  79 
38.  Preparing the AF Form 1403, Roster of Seriously Ill/Very Seriously Ill. ................  80 
39.  Responsibility for Preparing Death Cases. ..............................................................  81 
40.  Policies Regarding Deaths. .....................................................................................  81 
41.  Performing Postmortem (Autopsy) - Non-Forensic Cases. .....................................  83 
42.  Disposition of Outpatient Records on Deceased AD Personnel. .............................  85 
43.  Deceased Patient Kit. ..............................................................................................  85 
Section 4J—Birth Registration Program Administration    86 
44.  Birth Registration in the CONUS. ...........................................................................  86 
45.  Registering Births Overseas. ...................................................................................  86 
Section 4K—Medical Evaluation of Service Members for Continued Military Service    86 
46.  DELETED ..............................................................................................................  86 
47.  DELETED ..............................................................................................................  86 
48.  DELETED ..............................................................................................................  86 
49.  DELETED ..............................................................................................................  87 
50.  DELETED ..............................................................................................................  87 
51.  DELETED ..............................................................................................................  88 
52.  DELETED ..............................................................................................................  89 
53.  DELETED ..............................................................................................................  89 
54.  DELETED ..............................................................................................................  89 
55.  DELETED ..............................................................................................................  89 
56.  DELETED ..............................................................................................................  89 
57.  DELETED ..............................................................................................................  89 
58.  DELETED ..............................................................................................................  89 
59.  DELETED ..............................................................................................................  89 
60.  DELETED ..............................................................................................................  90 
61.  DELETED ..............................................................................................................  90 

AFMAN41-210  10 SEPTEMBER 2019  7 
62.  DELETED ..............................................................................................................  90 
63.  DELETED ..............................................................................................................  91 
64.  DELETED ..............................................................................................................  91 
65.  DELETED ..............................................................................................................  91 
66.  DELETED ..............................................................................................................  91 
67.  DELETED ..............................................................................................................  92 
68.  DELETED ..............................................................................................................  92 
69.  DELETED ..............................................................................................................  94 
70.  DELETED ..............................................................................................................  94 
71.  DELETED ..............................................................................................................  94 
72.  DELETED ..............................................................................................................  94 
73.  DELETED ..............................................................................................................  95 
Section 4L—Tumor Registry Program Administration    97 
74.  The Tumor Registry Program..................................................................................  97 
Chapter 5—HEALTH RECORDS MANAGEMENT    98 
Section 5A—General Program Administration    98 
1.  Managing Health Records. ......................................................................................  98 
2.  Documenting Health Records. ................................................................................  99 
3.  Correcting Health Records. .....................................................................................  99 
4.  The Electronic Health Record. ................................................................................  101 
5.  Electronically-Generated Forms. .............................................................................  110 
6.  Overprinting of Forms.............................................................................................  111 
7.  Service Treatment Record Disposition Instructions for Airman Retiring, 
Separating and Transitioning to the RC. .................................................................  112 
8.  Base Closures and Medical Records Management. .................................................  135 
9.  Health Record Review Committee/Functions. ........................................................  136 
Section 5B—Outpatient Records Administration    137 
10.  Creation of Outpatient Record Folders. ...................................................................  137 
Table  5.1.  Preparing Outpatient Record Folders Table. ...........................................................  137 
11.  Labeling File Folders. .............................................................................................  140 
Table  5.2.  Terminal Digit Health Record Filing System. .........................................................  140 
12.  Contents of the Outpatient Record. .........................................................................  142 
13.  Filing Outpatient Records. ......................................................................................  146 

AFMAN41-210  10 SEPTEMBER 2019 
14.  Managing ARC Outpatient Records. .......................................................................  148 
15.  Active Association and Geographically Separated Unit Outpatient Records 
Management. ...........................................................................................................  149 
Figure  5.1.  Sample GSU Label..................................................................................................  152 
Figure  5.2.  Sample GSU Record Copy ......................................................................................  152 
16.  Custody and Control of Health Records. .................................................................  152 
17.  Filing Outpatient Computer Generated Clinical Diagnostic Results. ......................  154 
18.  Researching Appropriate Host MTF Record Locations. .........................................  155 
19.  Loose Leaf, Orphaned, or Miscellaneous Medical Documents. ..............................  156 
20.  Missing and Lost Health Records............................................................................  159 
21.  Health Records Availability, Accountability, and “Tracking” Standards. ...............  160 
22.  Medical Documentation Requirements for Partial Hospitalization. ........................  167 
23.  Supplemental Documentation Guidance. ................................................................  168 
24.  Mental Health Records Documentation Requirements. ...........................................  168 
25.  Prenatal Records Documentation Requirements. ....................................................  168 
26.  Family Advocacy Program (FAP) Documentation Requirements. ..........................  169 
27.  Documentation Requirements to Support Graduate Medical Education Programs.   169 
28.  Managing Service Treatment Records for Service Members Assigned to the 
Personnel Reliability Assurance Program and Presidential Support Program .........  169 
29.  Transferring Health Records Between MTFs or Medical Units. .............................  170 
30.  Providing Health Records to AD Members During Temporary Duty Periods. ........  176 
Section 5C—Inpatient Records Administration    177 
31.  Creating Inpatient Records. .....................................................................................  177 
32.  Creation of the Master Patient Index. ......................................................................  178 
33.  Preparing Inpatient Record Folders. ........................................................................  178 
Table  5.3.  Preparing Inpatient Record Folders. ........................................................................  178 
34.  Contents of the Inpatient Record. ............................................................................  179 
35.  Inpatient Record Documents, Forms, and Patient Identification. ............................  180 
36.  Filing Inpatient Records. .........................................................................................  180 
37.  Coding and Documenting Inpatient Records. ..........................................................  181 
38.  Prenatal Records. ....................................................................................................  187 
39.  The Extended Ambulatory Record. .........................................................................  187 
40.  Creating, Coding, and Documenting, Ambulatory Procedure Visit Records. ..........  187 

AFMAN41-210  10 SEPTEMBER 2019  9 
5.41.  Creating, Coding, and Documenting Observation Records. ....................................  189 
5.42.  Patients Discharged Without Definitive Diagnosis. ................................................  190 
5.43.  Disposition of Inpatient Records. ............................................................................  190 
5.44.  Medical Transcription. ............................................................................................  191 
Section 5D—Deployed Assignment Medical Record Management    192 
5.45.  Minimum Deployed Medical Documentation and Record Management 
Requirements. .........................................................................................................  192 
5.46.  Expeditionary Electronic Health Record Management Platforms and Systems. .....  195 
5.47.  Emergency Medical Service and AF Form 552, Air Force Patient Care Report. ....  195 
Attachment 1—GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION    196 
Attachment 2—SECRETARY OF THE AIR FORCE DESIGNEE EXAMPLE REQUEST    212 
Attachment 3—CONSULT NOTES AND SPECIALTY STUDIES GUIDE    214 
Attachment 4—INITIAL RILO COVER SHEET/ CHECKLIST    216 
Attachment 5—PERSONNEL RELIABILITY ASSURANCE PROGRAM ADMIN CERT 
HAIMS SCAN GUIDE    218 
Attachment 6—ARRANGEMENT OF FORMS IN THE AF FORM 2100A SERIES, 
HEALTH RECORD OUTPATIENT SECTION 1    220 
Attachment 7—ARRANGEMENT OF FORMS IN THE AF FORM 2100A SERIES, 
HEALTH RECORD OUTPATIENT SECTION 2    224 
Attachment 8—ARRANGEMENT OF FORMS IN THE AF FORM 2100A SERIES, 
HEALTH RECORD OUTPATIENT SECTION 3    225 
Attachment 9—ARRANGEMENT OF FORMS IN THE AF FORM 2100A SERIES, 
HEALTH RECORD OUTPATIENT SECTION 4    227 
Attachment 10—ARRANGEMENT OF FORMS IN THE INPATIENT RECORD    229 
Attachment 11—SERVICE TREATMENT RECORDS MAILING ADDRESSES FOR 
OTHER SERVICES    233 
 

10 AFMAN41-210 10 SEPTEMBER 2019

Chapter 1

OVERVIEW, ROLES AND RESPONSIBILITIES

Section 1A—TRICARE

1.1. TRICARE Overview. TRICARE is the Department of Defense’s (DoD) managed

healthcare program for active duty (AD) military and their families, Reserve Component (RC)

members and their families, retirees and their families, and other beneficiaries. The TRICARE

Program offers options for healthcare coverage including: TRICARE Prime, TRICARE Select,

TRICARE Prime Remote, TRICARE for Life, TRICARE Plus, TRICARE Young Adult, and

several other programs. For detailed information on the various TRICARE health plans and to

access the TRICARE manuals go to the TRICARE website at https://manuals.health.mil/.

Throughout this AFMAN, the TRICARE Operations and Patient Administration staff are

responsible for the execution of the programs and processes outlined, unless explicitly stated.

1.2. TRICARE Operations Overview. The following activities are functions of TRICARE

Operations: managed care support, beneficiary counseling and assistance, debt collection

assistance, medical in/out-processing briefings, TRICARE plan marketing and education, health

plan analysis, enrollment management, external resource sharing agreements, clinical support

agreements, and the referral management center.

Section 1B—Patient Administration

1.3. Patient Administration Overview.

1.3.1. Patient Administration provides healthcare support services as part of the delivery of

basic and comprehensive medical treatment to eligible beneficiaries and manages or provides

appropriate guidance and oversight of all aspects of medical records functions within the

Military Treatment Facility (MTF).

1.3.2. The following activities are functions of Patient Administration: admissions and

dispositions, birth registration, death processing, casualty reporting, inpatient records

management, HIPAA privacy compliance, non-clinical aeromedical evacuation duties, line of

duty (LOD) determinations/coordination, outpatient records management, medical evaluation

boards administration, physical evaluation board liaison officer, organ donor program, patient

registration, release of information, Secretary of the Air Force designee program, sensitive

duties program records management, and the tumor registry program administration.

1.4. Patient Administration Officer, Director and Noncommissioned Officer (NCO).

1.4.1. The MTF commander or director will appoint a Patient Administration Officer,

Director, Senior NCO (SNCO) or NCO, depending on the size of the MTF, to manage and

provide oversight of all patient administration functions performed throughout the MTF. (T-

3). The individual appointed by the MTF commander or director has primary authority to

facilitate and/or enforce the policies, on behalf of the commander, identified in this manual.

1.4.2. Responsibilities: The Patient Administration Officer, Director, SNCO or NCO will

manage functions listed in paragraph 1.3.2. (T-1).

AFMAN41-210 10 SEPTEMBER 2019 11

1.5. HIPAA Privacy Officer. The duties and responsibilities of the MTF HIPAA privacy officer

are discussed in AFI 41-200, Health Insurance Portability and Accountability Act (HIPAA).

1.6. Registered Health Information Administrator (RHIA), Registered Health Information

Technician (RHIT), or Air Force member with equivalent education and experience.

1.6.1. The RHIA or RHIT must be credentialed by the American Health Information

Management Association, and if a civilian, must be rated eligible by the Office of Personnel

Management (OPM) Qualification Standard for the GS 669 or GS 675 series. (T-1).

1.6.2. The RHIA or RHIT will manage the inpatient records department, inpatient records

coding, and inpatient professional service encounters (rounds), ambulatory procedure visits,

medical transcription, outpatient record documentation, and coding oversight.

1.6.3. The RHIA or RHIT will work closely with the Information System Security Office and

HIPAA privacy officer to ensure security of, and controlled access to, both the paper-based

and automated medical records, and ensure release of information procedures conform to all

legal requirements.

Section 1C—Medical Coding

1.7. Medical Coders. For recording diagnoses and procedures, MTFs will include in their

position descriptions (PD) that coding staff will be required to complete the appropriate training

and certification exam from the American Academy of Professional Coders or American Health

Information Management Association within 18 months of placement under the PD indicated for

their position in accordance with Defense Health Agency Interim Procedures Memorandum

(DHA-IPM) 18-016, Medical Coding of the DoD Health Records.

1.7.1. Professional Services Coding: certified professional coder, American Academy of

Professional Coders; or certified coding specialist-physician, American Health Information

Management Association.

1.7.2. Institutional (Facility) Coding: certified outpatient coder (outpatient facility only),

certified inpatient coder (inpatient facility only), American Academy of Professional Coders;

or certified coding specialist, American Health Information Management Association.

1.7.3. An American Health Information Management Association RHIT or RHIA credential

may be counted in lieu of the certified coding specialist or certified coding specialist –

physician credential.

1.8. Air Force Medical Operations Agency (AFMOA) Coding Program Office. The AFMOA

Coding Program Office will be the office of primary responsibility for all Air Force Medical

Service (AFMS) coding related issues, composed of the Coding Manager and the AFMOA Coding

Consultants.

1.8.1. Responsibilities:

1.8.1.1. Represent the AFMS in tri-Service meetings and discussions involving coding

policy and guidance.

1.8.1.2. Provide program management oversight, expertise, and technical support to

AFMS coding operations.

12 AFMAN41-210 10 SEPTEMBER 2019

1.8.1.3. Define coder qualifications and provide AFMS coder manning and funding

recommendations.

Section 1D—Unit Commanders

1.9. Unit Commanders. The responsibilities of the unit commander are discussed throughout

this AFMAN. In particular commander authorizations, notifications and coordination with MTF

staff may occur. See paragraphs 2.9, 2.18.4, 2.20.2, 4.11.2, 4.23.10, 4.24, 4.50.4, 4.65.8, 4.68.5,

5.4.5, 5.7.2.4, 5.15.6, 5.21.5.7.

Section 1E—Administrative Assistant to the Secretary of the Air Force (SAF/AA)

1.10. SAF/AA. The responsibilities of SAF/AA include delegated authority of the Air Force

Secretarial Designee Program. See paragraphs 4.13, 4.14, 4.15.

AFMAN41-210 10 SEPTEMBER 2019 13

Chapter 2

HEALTHCARE BENEFITS AND REQUIREMENTS

Section 2A—Healthcare Entitlements for Current and Former Uniformed Services Personnel

and Foreign Forces Members

2.1. General Administration of Healthcare Benefits. MTFs will administer healthcare benefits

to uniformed service members, family members, retirees, and other eligible persons in accordance

with Department of Defense Directive (DoDD) 6010.04, Healthcare for Uniformed Services

Members and Beneficiaries, and Health Affairs Policy 11-005, TRICARE Policy for Access to

Care. (T-0).

2.1.1. MTFs will provide care without regard to the sponsor’s Service affiliation, rank or

grade. (T-0).

2.1.2. Active Duty (AD) service members must be enrolled to TRICARE Prime. (T-0).

Reference Health Affairs Policy 05-014, Policy Guidance for Active Duty Service Member

Enrollment to TRICARE Prime and 32 CFR Part 199.17, TRICARE program.

2.1.3. Eligibility Verification. MTFs will require that all persons, including members in

uniform, show satisfactory evidence of their beneficiary status before receiving MTF care. (T-

0). MTFs will not provide routine care to patients whose eligibility cannot be verified unless a

competent medical authority determines a delay in care would create an unreasonable risk to

the patient’s health. (T-0). In such cases, the MTF will require the patient to sign a statement

of eligibility that indicates the patient’s requirement to provide proof of eligibility within 30

days or be held responsible for the costs associated with the care provided. (T-0). After the

30th day, if the individual has not produced evidence that satisfactorily verifies eligibility, the

TRICARE Operations and Patient Administration Flight will forward the patient’s information

to the Resource Management Flight to initiate the billing process. (T-1). This process applies

to outpatient care, inpatient care, and ancillary care; however, for emergency cases, MTFs will

always provide care first and verify eligibility after treatment. (T-0). The Military Personnel

Section (MPS) establishes eligibility, whereas the MTFs verify eligibility. Reference: 10 USC

Chapter 55, “Medical and Dental Care;” DoDI 1341.02, Defense Enrollment Eligibility

Reporting System (DEERS) Program and Procedures and AFI 36-3026_IPV1, Identification

Cards for Members of the Uniformed Services, Their Eligible Family Members, and Other

Eligible Personnel.

2.1.3.1. MTFs will require that all patients requesting care present a valid government

identification card that satisfactorily establishes the identity of the patient except when the

patient is aged 10 or under. (T-0). Beneficiaries aged 10 and under may receive MTF care

without providing a valid government identification when the child passes a Defense

Enrollment Eligibility Reporting System (DEERS) check and a legally authorized

representative with a military identification validates the child’s identity. Legally

authorized representatives who lack a military identification may not validate the child’s

identity. In cases where the legally authorized representative lacks military identification,

the child must show government identification that satisfactorily confirms the child’s

identity. (T-0).

14 AFMAN41-210 10 SEPTEMBER 2019

2.1.3.2. MTFs will perform DEERS checks for eligibility on all patients requesting care.

(T-0). Eligible beneficiaries enrolled in a Uniformed Services Family Health Plan are not

eligible for routine care at MTFs; however, all other patients reflecting eligibility in

DEERS are authorized care within MTFs. RC service members and their family members

who present a government, state or country photo identification card and pass a DEERS

check should not be asked for a copy of AD orders.

2.1.3.2.1. If a patient fails a DEERS check, MTFs may still provide routine care within

the direct care system in the following circumstances and as otherwise authorized in

this manual, or by statute:

2.1.3.2.1.1. The patient is a member of the RC on active or inactive duty for less

than 30 days and presents a copy of their orders or other administrative

documentation.

2.1.3.2.1.2. The patient is a member of the RC on active or inactive duty status,

and is seeking healthcare related to an in line of duty (LOD) medical or dental

condition or a condition which is currently under LOD investigation in accordance

with AFI 36-2910, Line of Duty (LOD) Determination, Medical Continuation

(MEDCON) and Incapacitation (INCAP) Pay.

2.1.3.2.1.3. If a RC service member is issued delayed-effective-date AD orders for

more than 30 days in support of a contingency operation, the member and the

member’s family are eligible for early TRICARE medical and dental benefits

beginning on the latter of either: (a) the date their orders were issued or (b) 90 days

before the service member reports for duty or is activated to AD.

2.1.3.2.1.4. The patient has a Secretarial Designee letter that authorizes the care.

Ensure the patient only receives care limited to the specific dates and diagnosis

annotated in the approval letter. (T-0).

2.2. RC Members. MTFs will administer health benefits to RC service members on AD tours,

on AD orders, and under circumstances directed in Department of Defense Instruction (DoDI)

1241.01, Reserve Component (RC) Line of Duty Determination for Medical and Dental Treatments

and Incapacitation Pay Entitlements and AFI 36-2910. (T-0).

2.2.1. When not in an Extended Active Duty military status (orders for greater than 30 days),

TRICARE Early Mobilization or Transitional Assistance Management Program status; RC

member military healthcare is limited. Refer to DoDI 1241.01 for entitlements.

2.2.2. RC service members placed on orders for more than 30 days for non-contingency

related operations are authorized TRICARE benefits equal to the AD component.

Additionally, TRICARE benefits are extended to the RC service member’s authorized family

members during the same period.

2.2.2.1. Officer direct accessions: Members commissioned as reserve officers in the

uniformed services may be entitled to full medical and dental benefits prior to commencing

AD service on Extended AD orders when: Extended AD orders will be issued but have

not been issued yet, or the orders have been issued but the member has not yet entered AD;

and the member does not have healthcare insurance and is not covered by any other health

plan. Reference 10 USC § 1074.

AFMAN41-210 10 SEPTEMBER 2019 15

2.2.2.2. (Added) MTFs will ensure RC service members undergoing an LOD in

accordance with paragraph 4.12 receive thorough hand-off between facility providers and

supporting reserve medical unit or civilian providers.

2.2.3. RC service members ordered to Federal AD for more than 30 days in support of

contingency operations are also authorized full TRICARE benefits. Healthcare coverage is

also extended to each of the RC service member’s authorized family members. Additionally,

if the RC service member is issued delayed-effective-date AD orders for more than 30 days in

support of a contingency operation, the member and sponsored family members are eligible

for early TRICARE medical and dental benefits beginning on the latter of either: (a) the date

orders were issued or (b) 180 days before the member reports for duty or is activated to AD.

2.2.4. Air Reserve Component (ARC) members do not have to be in a duty status to make an

appointment. However, the member must show they are on duty status (active, inactive or

points only) at the time of any treatment/care (i.e. any annual military requirement exam,

immunization, or deployment-related exam). (T-1). MTFs verify ARC members are in a duty

status (active, inactive, or points only) for annual military requirements such as Periodic Health

Assessment, flight physicals and immunizations with the AF Form 40A, Record of Individual

Inactive Duty Training, or a copy of the member’s orders.

2.3. Foreign Forces and Their Dependents. MTFs will provide healthcare to foreign forces,

and their eligible dependents when applicable, in accordance with DoDI 6025.23, Health Care

Eligibility Under the Secretarial Designee (SECDES) Program and Related Special Authorities,

DoDI 6015.23, Foreign Military Personnel Care and Uniform Business Offices in Military

Treatment Facilities (MTFs); DoDI 1000.13, Identification (ID) Cards for Members of the

Uniformed Services, their Dependents, and other Eligible Individuals. (T-0).

2.3.1. MTFs will provide authorized care for the categories of foreign nationals listed below,

and seek reimbursements that are consistent with international agreements (i.e. Status of Forces

Agreement or Reciprocal Health Care Agreement). (T-0). If a Reciprocal Health Care

Agreement exists that establishes different benefits or charges from those associated with a

training program, then the Reciprocal Health Care Agreement takes precedence. Foreign

nationals and their family members must present approved identification and/or Invitational

Travel Orders as appropriate when requesting care. (T-0). Treatment of foreign nationals and

their family members is subject to the provisions of approved international agreements.

2.3.1.1. North Atlantic Treaty Organization (NATO) and Partnership for Peace Status of

Forces Agreement personnel and their authorized family members eligibility is determined

by DoDI 6015.23.

2.3.1.2. Foreign diplomatic or other senior foreign officials and the dependents of such

officials may be provided inpatient or outpatient services in MTFs only in compelling

circumstances, including both medical circumstances and mission interests, and through

case-by-case approval. Refer to DoDI 6025.23.

2.3.1.3. Foreign military personnel assigned or attached to United States military units for

duty and their family members eligibility is determined by DoDI 6015.23.

2.3.1.4. International students assigned or attached to United States military units for

training and their authorized family members eligibility is determined by DoDI 6015.23.

16 AFMAN41-210 10 SEPTEMBER 2019

2.3.1.5. Detainees, Enemy Prisoners of War, refugees, and other displaced personnel will

be provided medical care equal to that of United States Service Members. See for example,

Article 91 of Geneva Convention Relative to the Protection of Civilian Persons in Time of

War of August 12, 1949: 75 U.N.T.S. 287 (1950) which can be located at

https://ogc.osd.mil/LoW_Treaties.html. Consult with Staff Judge Advocate regarding

Law of War compliance.”

2.4. Cadets and Midshipmen. MTFs will administer health benefits to cadets enrolled at the

United States Air Force Academy, the United States Military Academy at West Point, the United

States Coast Guard Academy, and midshipmen enrolled at the United States Naval Academy. (T-

0). Enrollment into TRICARE is authorized. Reference 10 USC § 1074b.

2.5. Senior College or University Reserve Officer Training Corps (ROTC) Cadets; ROTC

Membership Applicants; Uniformed Service Applicants; and Service Academy

Applicants. MTFs will provide limited healthcare to ROTC Cadets and applicants to the Service

Academies, ROTC and the Uniformed Services. (T-0). Reference 10 USC § 1074b.

2.5.1. MTFs will provide cadets medical and dental care for any injury or illness incurred

while traveling to and from, and participating in, any summer field training or other practical

military training. (T-0)

2.5.2. If a ROTC cadet’s college, university, or institution does not have the ability to perform

a physical exam, the cadet will be provided an examination(s) at a MTF, per Health Affairs

Policy 99-003, Physical Examination for ROTC Applicants, including admission if required to

satisfy clinical diagnostic requirements. (T-0). Uniformed Service or Service Academy

applicants may receive initial service eligibility examination(s) at a MTF. For remedial ROTC

commissioning, Uniformed Service, or Service Academy entrance examinations that require

additional diagnostic care beyond a MTFs capabilities, refer the cadet or applicant to the closest

MTF (with the required capabilities) for required medical testing.

2.5.3. Cadets requiring additional follow-up medical care after hospitalization and/or after

completing summer training, military exercise training, practical military training, etc., are

authorized Department of Defense (DoD) MTF care only, regardless of the cadet’s distance

from a MTF.

2.6. Medal of Honor Recipients. MTFs will administer medical and dental benefits to otherwise

non-eligible Medal of Honor recipients and their immediate dependents as if the Medal of Honor

recipient is a retiree entitled to retired pay. (T-0). Reference 10 USC § 1074h.

Section 2B—Healthcare for Current and Former Uniformed Service Family Members

2.7. Un-remarried Former Spouses. MTFs will administer healthcare benefits to certain un-

remarried former spouses of Uniformed Service Members. (T-0). Reference 10 USC § 1072 and

1086a.

2.8. Abused Family Members and Dependents. MTFs will administer health benefits to abused

family members and dependents in accordance with 32 CFR Part 199.3, DoDI 1342.24,

Transitional Compensation for Abused Dependents, and in accordance with 10 USC § 1076,

1408(h), 1059. (T-0).

AFMAN41-210 10 SEPTEMBER 2019 17

Section 2C—Healthcare for Eligible Civilians and Special Categories of Beneficiaries and

Their Family Members

2.9. Federal Civilian Employees. MTFs will provide limited health care to Federal civilian

employees in accordance with DoDI 1400.32, DoD Civilian Work Force Contingency and

Emergency Planning Guidelines and Procedures; DoDI 6490.03, Deployment Health; and Health

Affairs Policy 08-002, Policy for Billing Care Furnished by Military Treatment Facilities to

Federal Employees for On-the-Job Injuries and for Occupational Health to support DoD civilian

personnel deployment and occupation health. (T-0).

2.9.1. Conditional Employment/Annual Occupational Exam Requirements. MTFs will

provide occupational exams when they have the capability. (T-3). Reference 5 Code of Federal

Regulations 339.301, Authority to Require an Examination.

2.9.1.1. When the local MTF does not have the capability to provide a medical

examination (or a portion of the exam) required for Air Force civilian employment, then

the MTF may arrange to have the examination (lab tests, etc.) completed in the civilian

sector (non-DoD) healthcare community after receiving payment authorization from the

employee’s unit commander.

2.9.1.2. The employee’s unit commander must authorize payment for all civilian sector

(non-DoD) examinations in advance of the MTF making the arrangements. (T-1). Payment

is made from the same appropriation that funds the employee’s salary. The Defense Health

Program appropriation will not be used for the examinations, unless the employee’s salary

is Defense Health Program-funded (e.g., a MTF employee). (T-0).

2.9.1.3. The Installation Occupational and Environmental Medicine Consultant will

provide clinical oversight of referrals/consults to ensure they are appropriate and justified.

(T-3).

2.9.1.4. The MTF provider’s support staff will notify the MTF Resource Management

Office (RMO) that a private sector exam is needed for a civil service employee (the clinic

must include the estimated cost of the exam or test). (T-3).

2.9.1.5. The RMO will send a request for unit commander’s Authorization of Payment for

Civilian Medical Exam packet to the employee’s unit commander. (T-3). The packet

contains two attachments: (1) Commander’s Authorization of Payment for Civilian

Medical Exam, and (2) Instructions for the unit resource advisor.

2.9.1.6. Commander’s Authorization of Payment for Civilian Medical Exam: This letter

serves as the MTF’s authorization to process the employee’s referral. It also expresses the

unit commander’s acknowledgement that unit funds will be used for payment of the exam.

(T-3).

2.9.1.7. Instructions to unit resource advisor: This information sheet explains to the

employee’s unit resource advisor the steps the advisor must take in order for payment to

be made to the civilian healthcare provider. (T-3). Payment will not be made until exam

results are received by the MTF. (T-3).

2.9.1.8. Once the RMO receives the unit commander’s Authorization of Payment for a

Civilian Medical Exam from the employee’s unit, a copy is provided to the MTF clinic.

The clinic will then schedule the employee’s exam. (T-3).

18 AFMAN41-210 10 SEPTEMBER 2019

2.9.1.9. The MTF clinic that schedules the employee’s exam should emphasize to the

civilian sector provider’s office that results of the exam and the associated invoice for full

and final payment must be sent to the MTF’s Referral Management Center. (T-3). Note:

MTF must provide the address, fax, and point of contact information. (T-3).

2.9.1.10. The Referral Management Center will: (1) Forward the exam results to the MTF

provider that requested the exam, and (2) Forward the invoice for the exam to RMO. (T-

3).

2.9.1.11. The RMO will: (1) Verify that the invoice contains “Full” or “Final” payment

on the invoice. If the invoice does not state that it is for full/final payment, then RMO

should contact the civilian provider’s billing office in order to receive a revised bill; (2)

Process payment according to the option indicated by the employee’s unit commander on

the bottom of the Commander’s Authorization of Payment for Civilian Medical Exam, and

per the Instructions to the unit resource advisor. The RMO should not proceed with

payment until exam results are received by the MTF. (T-3).

2.9.2. Workers’ Compensation Eligibility for Medical Services. Under the Federal

Employee’s Compensation Act, an employee injured while in the performance of duty is

entitled to compensation. This compensation may include services, appliances, and supplies

prescribed or recommended by a qualified physician. The Secretary of Labor must consider

the compensation likely to cure, give relief, and reduce the degree or period of disability or aid

in lessening the amount of monthly compensation. Reference 5 USC § 8103. Said services,

appliances, and/or supplies may be furnished by MTFs, Veterans Affairs (VA), or, United

States Public Health facilities; however, this instruction does not guarantee that the required

service(s) or supplies will be available at any one particular MTF, VA, or, United States Public

Health facility. When the local MTF has the capacity and supplies to provide this care, the

employee may choose to seek care through either the MTF or the civilian sector.

2.9.2.1. Direct MTF medical care, also known as in-house care, for job related injuries or

illnesses require: (1) Presentation of a completed Department of Labor Form LS-1,

Request for Examination and/or Treatment, LS-201, Notice of Employee’s Injury or Death,

or LS-202, Employer’s First Report of Injury or Occupational Illness along with Form

Compensation Act (CA)-16, Authorization for Examination and/or Treatment. A separate

Form CA-16 is not required for each episode of follow-up care if a Form CA-16 was

provided on the initial visit. If follow-up care is required beyond 60 days of the initial

issuance of the Form CA-16, the supervisor contacts the United States Department of Labor

(DOL) for authorization to issue another Form CA-16; (2) the care being provided is for

the same illness or injury as on the initial visit; and (3) the MTF has the capability to

provide the care.

2.9.2.1.1. A Form CA-16 authorizes an injured employee to obtain a medical

examination and/or treatment for up to 60 days. The Form CA-16 is used to authorize

payment for medical care of injuries only and cannot be used for illnesses. The Form

CA-16 is required for MTF care and prior to referring the patient outside of the MTF

for a consult or special study.

2.9.2.2. If the patient is referred/transferred to a specialist, the worker’s supervisor will

complete the Form CA-16 to authorize payment to the specialist (again, only for the first

60 days following injury). (T-1). The form is prepared by the individual’s supervisor and

AFMAN41-210 10 SEPTEMBER 2019 19

must be presented prior to treatment outside the MTF unless it is a medical emergency. (T-

1). In an emergency, the supervisor prepares the form within 48 hours after treatment is

rendered. If a Form CA-16 is created, a copy is scanned/uploaded into the individual’s Air

Force electronic health record. The MTF Patient Administration function does not provide

advice to employees or supervisors regarding form completion. Refer to the United States

Department of Labor, Office of Worker’s Compensation Programs.

2.9.3. Non-Deployment, non-work related illness/injury MTF Healthcare. Federal civilian

employees may be provided limited MTF medical treatment at the discretion of the MTF

commander or director for non-work related conditions on an outpatient basis for the purpose

of preventing excessive loss of duty time, or when immediate occupational requirements

dictate. Outpatient MTF medical care provided to federal civilian employees must be limited

to urgent relief of minor illnesses (e.g., sunburn, insect bite/stings, etc.) during the duty period

when care from a private medical provider would require a disproportionate amount of time

lost from the job. (T-1). The MTF commander or director must limit treatment to what is

needed to complete the work shift. (T-3). Surgical procedures, intravenous fluids and

prolonged course of care should not be provided. Controlled substances must not be

administered. (T-1). If simple outpatient medical care is approved by the MTF commander or

director and care is provided, the MTF should not assume responsibility for continued

treatment for any condition that could not be reasonably resolved during the initial episode of

treatment.

2.9.4. Federal Civilian employees employed outside the United States. Federal civilian

employees employed outside the United States who require treatment for conditions not

covered by the Office of Workers’ Compensation Program, who are not beneficiaries of any

other federal agency listed in this chapter, and dependents of such employees may receive

space available care in MTFs outside the United States. Charges will be collected locally in

accordance with DoD 6010.15-M, MTF Uniformed Business Office Manual, from the

individual at the interagency rate, except that no charge will be made for immunizations

authorized by AR 40-562/BUMEDINST 6230.15B /AFI 48-110/CG COMDTINST

M6230.4G, Immunizations and Chemoprophylaxis for the Prevention of Infectious Diseases,,

or for occupational health services as authorized elsewhere in this chapter. (T-0).

2.9.5. Non-Appropriated Fund employees. Non-Appropriated Fund employees are generally

not considered to be United States Government employees for most benefits, but may receive

occupational health services such as pre-employment, pre-deployment, and annual physicals

at MTFs in accordance with Health Affairs Policy 08-002. Such services are billed to the Non-

Appropriated Fund instrumentality.

2.9.6. Armed Forces Retirement Home. Title 24 United States Code Section 411 establishes

the Armed Forces Retirement Home as an independent federal organization. The purpose of

the Armed Forces Retirement Home is to provide residences and related services to certain

retired and former members of the Armed Forces in two locations—the Washington, D.C. area

and the Gulfport, MS area. Title 24 United States Code Section 413 authorizes the DoD to

provide secondary and tertiary hospital care, to the extent available, for both retiree and non-

retiree residents that is not available at the Armed Forces Retirement Home itself. As such,

Armed Forces Retirement Home residents do not require Secretarial Designation and are

eligible for secondary and tertiary hospital care at those MTFs that have been identified by the

DoD to provide these services (currently the Walter Reed National Military Medical Center

20 AFMAN41-210 10 SEPTEMBER 2019

and Keesler Air Force Base). Armed Forces Retirement Home leadership is responsible for

transportation to and from these MTFs.

2.10. Family Members (Dependents) of Federal Civilian Employees. When available, MTFs

will provide limited care to dependents who reside overseas under applicable laws and directives.

(T-0). Reference AFI 36-3026_IPV1; 24 USC § 34; DoDI 6000.11, Patient Movement; DoDI

6025.23. When their civil service sponsor is stationed overseas, family members are eligible to

receive space available healthcare and space available routine dental at MTFs at the Interagency

Outpatient Rate or Interagency Rate. Family members of civilians stationed in the United States

are not eligible for any routine healthcare or dental at MTFs.

2.11. Secretarial Designees. MTFs will administer medical and dental care to secretarial

designees, when applicable, in accordance with DoDI 6025.23. (T-0).

2.12. Members of Uniformed Services Auxiliaries. MTFs will provide limited healthcare to

senior adult and cadet members of the Uniformed Services Auxiliaries, who are injured while on

official government business. (T-0).

2.13. Emergency Care. Medical and dental care is authorized to the extent necessary to save life

or limb and prevent undue suffering. Patients are transferred to a civilian medical facility as soon

as they are stabilized. Collect the full-reimbursement rate from the individual or the individual’s

insurance company.

2.14. Contractors.

2.14.1. MTFs will provide care in accordance with contract terms and applicable laws and

policies to support contractor deployments and occupational health requirements. (T-0).

Elective care is not authorized, and in most instances, routine care is not authorized. Always

check the contract for specific terms. Reference DoDI 3020.41, Operational Contract Support.

2.14.2. MTF Contractor Occupational Health. Exams, evaluations, and immunizations

necessary to comply with MTF occupational health requirements are authorized at MTFs,

except when the provision of these occupational health services are designated as a contractor

responsibility under the terms of the contract.

2.15. Family Members (Dependents) of Contractors. Contractors may request approval from

the overseas Major Command (MAJCOM) Commander for medical care for their family members

beyond emergency care when specified requirements are met. Agreements reached under this

paragraph are annotated in the annual report for Secretarial Designees. Elective care is not

authorized. (T-1).

2.16. Expanded Medical Care for Caregivers. MTFs will inform individuals designated as

caregivers for seriously ill/very seriously ill service members of their authorization for space-

available inpatient/outpatient medical care at MTFs. (T-0). Reference 38 USC 1720G, Assistance

and support for caregivers.

2.17. Volunteers. MTFs will treat DoD volunteers, who are not TRICARE eligible, as federal

employees for volunteer-related injury or stabilization for illness. (T-0). Reference 10 USC §

1588, 5 USC § 8103, 5 USC § 8141 and DoDI 1100.21, American Red Cross (ARC)-DoD MOU.

If a DoD volunteer, regardless of volunteer organization affiliation, e.g., Red Cross, military retiree

activities office, etc., is normally entitled to MTF Direct Care or TRICARE benefits, then provide

the necessary healthcare coverage without delay. Otherwise, volunteers may be authorized

AFMAN41-210 10 SEPTEMBER 2019 21

outpatient and inpatient direct MTF healthcare for volunteer-related injury or illness for

stabilization.

Section 2D—Other Services and Authorizations

2.18. Additional MTF Requirements

2.18.1. Healthcare at Department of VA and Other Government Agencies. MTF commanders

or directors may authorize active duty and other DoD beneficiaries to receive space available

care at other federal agencies through resource sharing agreements. MTF commanders or

directors may also authorize beneficiaries from other federal agencies to purchase care from

MTFs when an appropriate agency official requests the services in writing from the MTF, and

the request will not interfere with medical care for persons entitled to MTF care. Reference

AFI 41-126, Department of Defense/Veterans Affairs Health Care Resource Sharing Program.

2.18.2. Dependency Determinations for Incapacitated Children. MTFs will process

dependency determinations for incapacitated children to assist in applying for continued

benefits for a child who becomes incapacitated before losing eligibility. (T-1). MTFs will

provide a medical sufficiency statement and follow process and eligibility guidance in AFI 36-

3026_IPV1. (T-1). Children enrolled in TRICARE Young Adult do not fall under the

provisions of this paragraph.

2.18.2.1. The Defense Finance and Accounting Service-Indianapolis Center is the final

approving authority for dependency determinations. The Military Personnel Section and

Base Finance Office will review the DD Form 137-5, Dependency Statement, and other

documentation to determine if the initial eligibility criteria warrant further processing and

forwarding to Defense Finance and Accounting Service-Indianapolis Center.

2.18.2.2. A medical statement in narrative format from the attending physician, or primary

care manager, including a medical sufficiency statement must be included in the

dependency determination application package provided from the MTF. (T-1). The MTF

commander or director is responsible for completing the Medical Sufficiency Statement;

however, the MTF commander or director may delegate the responsibility to the Chief of

the Medical Staff.

2.18.2.3. The patient and/or sponsor is responsible for obtaining and providing any

supporting medical documentation required for the application package. The TRICARE

Operations and Patient Administration Office will coordinate all requests for dependency

determinations with the Chief of Medical Staff. (T-3). Final medical sufficiency review

rests with the MTF commander or director, or Chief of Medical Staff if delegated. If the

MTF commander or director has delegated endorsement authority to the MTF/Chief of

Medical Staff, the application package does not need the MTF commander’s or director’s

signature before it is forwarded to officials at the installation personnel/finance office.

2.18.2.4. If the patient’s care is rendered outside of the MTF, and it would be a burden on

the patient or sponsor to travel to a MTF, a civilian provider may complete the medical

sufficiency statement and submit it to the nearest Air Force MTF for endorsement.

2.18.2.5. In order to establish medical incapacity, the patient’s illness must be substantial

and truly disabling. (T-1). In addition, the medical incapacity must occur before the

individual’s 21st birthday (or 23rd birthday if enrolled as a full-time student when

22 AFMAN41-210 10 SEPTEMBER 2019

incapacitation occurred). (T-1). The Air Force does not consider a diagnosis of alcoholism

or drug abuse as an incapacitating illness for the purposes of dependency determinations.

The likelihood of future medical expenditures and/or the existence of a medical condition

that will worsen over time, do not justify a determination of medical incapacity if no

incapacitation currently exists.

2.18.2.6. The civilian or MTF provider will include the following information in the

medical sufficiency statement (T-2):

2.18.2.6.1. Diagnosis (use medical and layperson’s terms).

2.18.2.6.2. Summary of the individual’s incapacitation, including the nature and extent

of the illness or disease. Non-medical personnel should be able to understand this

summary.

2.18.2.6.3. Explain how the incapacity affects the individual’s ability to perform

routine life activities, such as self-care.

2.18.2.6.4. Age when the incapacitation began (might not be the same as when medical

personnel diagnosed the illness or disease).

2.18.2.6.5. Probable duration of the incapacitation. Indicate if the incapacity predated

the individual’s 21st or 23rd birthday and has been continuous since diagnosis.

2.18.2.6.6. Based on the healthcare provider’s professional opinion, indicate if the

incapacity makes the individual incapable of self-support.

2.18.2.6.7. Depending on the circumstances involved in the sufficiency review, the

MTF commander or director/designee selects one of the four statements as described

in attachment 15 of AFI 36-3026_IPV1.

2.18.2.7. The MTF completing the Medical Sufficiency Statement shall provide the

sponsor with the completed request package; however, only an approved Medical

Sufficiency Statement must be submitted to Defense Finance and Accounting Service. (T-

1). The sponsor is responsible for coordinating with the appropriate finance and Military

Personnel Section officials.

2.18.2.8. A copy of the Medical Sufficiency Statement and any other supporting medical

documentation should be scanned/uploaded in the appropriate section of the patient’s

electronic health record.

2.18.2.9. The applicant may submit a request for reconsideration to the MTF commander

or director if there is new or compelling information. The MTF can review, and if the

commander determines a change from original recommendation to the Military Finance

Office is warranted, will notify that office. (T-2). Defense Finance and Accounting

Service-Indianapolis Center remains the ultimate decision authority for granting

dependency status based on the Medical Sufficiency Statement and financial support (over

50%) from the sponsor.

2.18.3. TRICARE Extended Care Health Option. MTFs will administer the TRICARE

Extended Care Health Option program in accordance with Title 32, Code of Federal

Regulations, Part 199.5(g), TRICARE Extended Health Care Options (ECHO), current edition

AFMAN41-210 10 SEPTEMBER 2019 23

and Title 32, Code of Federal Regulations, Part 199.7, Claims Submission, Review, and

Payment, current edition (T-0).

2.18.3.1. Extended Care Health Option Home Healthcare. Custodial care services, as

defined in Title 32, Code of Federal Regulations, Part 199.2, Definitions, current edition

may be provided to the extent such services are provided in conjunction with authorized

TRICARE Extended Care Health Option home healthcare services, including the Extended

Care Health Option Home Healthcare respite care benefit specified in this section.

Authorized beneficiaries will receive all home healthcare services and no portion will be

provided under the TRICARE Basic Program. (T-0). Reference 32 CFR Part 199.4(e).

2.18.4. Elective Medical Care from Civilian Sources for AD Members. Elective medical and

dental care provided at civilian medical facilities or from other civilian sources is not

authorized at the government’s expense. Service Members who seek medical/dental care

outside the Military Health System without prior approval or coordination with the MTF

responsible for their primary care, do so at their own risk. Any unfavorable outcome resulting

from elective care provided by civilian sources could result in a not-in-line-of duty finding and

potentially impact disability benefits. All members assigned or attached to a sensitive duty

program, e.g., the Personnel Reliability Program (PRP), Presidential Support Program (PSP),

or other national security dependent program, must obtain written permission from their unit

Commander and local MTF Commander prior to treatment. If approved, personnel in these

uniquely critical programs must have their treatment reviewed by the MTF PRP consultant or

designated competent medical authority. (T-1). In addition, any service member seeking

elective surgery must comply with AFI 44-102, Medical Care Management. (T-1).

2.18.4.1. Service members must arrange for the civilian medical facility to send a

summary of treatment to the servicing MTF. (T-1). For additional information regarding

elective civilian medical care for AD service members, refer to AFI 44-102 and AFI 36-

3003, Military Leave Program.

2.18.5. Requirements for Organ Donation Requests. All AD members must follow the

requirements in AFI 44-102 in order to serve as organ donors. (T-1).

2.18.6. Authorization for Physical Examinations Other than Flying.

2.18.6.1. Operational Health Assessments (Periodic Health Assessment, Mental Health

Assessment, Deployment-Related Health Assessment). Operational Health Assessments

are authorized in accordance with DoDI 6200.06, Periodic Health Assessment (PHA)

Program; DoDI 6490.03; and DoDI 6490.12, Mental Health Assessments for Service

Members Deployed in Connection with a Contingency Operation, and 10 US Code §1074.

Scheduling is managed by the Operational Medicine Clinic or Force Health Management

as determined by the MTF.

2.18.6.2. Civilian occupational health examinations are performed in accordance with 29

CFR §1910.

2.18.6.3. The MTF commander or director may authorize medical evaluations in the

context of a public health emergency in accordance with DoDI 6200.03, Public Health

Emergency Management within DoD; exposure to bloodborne pathogen in accordance with

29 CFR §1910.1030; and food safety in accordance with AFMAN 48-147, Tri-Service

Food Code.

24 AFMAN41-210 10 SEPTEMBER 2019

2.19. Primary Care Manager Assignments. MTFs shall provide enrollees with the opportunity

to register personal preferences for Primary Care Managers from a list of choices as required by

DoDI 6000.14, DoD Patient Bill of Rights and Responsibilities in the Military Health System

(MHS). (T-0). The MTF commander or director will also make a provider directory easily

accessible to beneficiaries, which is inclusive of all MTF Primary Care Managers alongside the

provider information required by DoDI 6000.14. (T-0).

2.19.1. MTFs shall not deny Primary Care Manager empanelment/enrollment to beneficiaries

based on the sponsor’s Service affiliation. (T-0). MTFs shall not deny patients the opportunity

to initiate Primary Care Manager changes by phone or by web through the Beneficiary Web

Enrollment application, or otherwise limit Primary Care Manager change requests to face-to-

face transactions. (T-1).

2.19.2. MTFs shall only make credentialed and privileged Primary Care Managers available

for empanelment. (T-1). Primary care managers loaded into DEERS and/or the Composite

Health Care System (CHCS) shall be entered using the credentialed provider's name as listed

in the MTFs provider directory, not team names or other names that are non-specific to a

particular credentialed and privileged provider. (T-1). MTFs shall not enter primary care

managers into DEERS or CHCS for short-term administrative purposes such as managing

disenrollment, over-enrollment, or provider panel acuity/complexity. (T-1). MTFs may allow

a recently departed primary care manager to remain in DEERS and/or CHCS temporarily until

the departed primary care manager’s panel can be transferred; however, one or more

credentialed and privileged providers must be accountable for the panel until it is transferred.

(T-1).

2.19.3. MTFs shall honor enrollee primary care manager preference requests subject to the

primary care manager’s availability, matching patient medical needs with the appropriate level

of healthcare provider, and other operational requirements established by the MTF commander

or director. (T-3). MTFs shall minimize primary care manager changes not requested by

enrollees, and shall not disrupt established patient-provider relationships for the sole purpose

of rebalancing provider panels; instead, provider panels should be balanced through new

patient enrollments and patient attrition. (T-3).

2.19.4. MTFs shall not initiate a primary care manager change that transfers an enrollee from

a MTF primary care manager to a network primary care manager unless the enrollee’s medical

needs exceed the MTFs capabilities. (T-1). MTFs planning any forced disempanelment of

beneficiaries require pre-approval from the Air Force Medical Support Agency and must

coordinate with the Defense Health Agency. (T-1). Poor patient behavior and/or non-

compliance with medical care are insufficient grounds to involuntarily disengage an enrollee

from a MTF primary care manager to a network primary care manager, except in rare

circumstances where the patient’s behavior is so abusive or belligerent that it significantly

interferes with execution of the MTF’s mission and threatens the safety and wellbeing of the

other patients and/or MTF staff. In these cases, the MTF should seek advice from the local

Staff Judge Advocate and regional Medical Legal Consultant. If legal authorities advise the

patient’s abusiveness or belligerency warrants disengagement of the patient from the MTF,

and that the individual’s entitlement to care doesn’t prevent transferring their care to the

network, the MTF shall coordinate a transfer of care to a network healthcare team to ensure

continuity of care. (T-3). If there is an immediate danger to staff or patients, the healthcare

team should contact security forces.

AFMAN41-210 10 SEPTEMBER 2019 25

2.19.4.1. In written documentation, the MTF commander or director will describe the

disruptive behavior, its effect, the investigative and determination process, and the

probable consequences of disruptive behavior. MTF leadership will consult their servicing

legal office early in all cases of disruptive beneficiary behavior.

2.19.4.2. When an active duty service member displays abusive or seriously disruptive

behavior in the MTF, the following actions are recommended:

2.19.4.2.1. Obtain objective assessment and documentation of the abusive behavior by

witnesses. Documentation should clearly demonstrate how the behavior threatens

patient or staff safety.

2.19.4.2.2. Advise the active duty service member of paragraph 2.19.4.5, referencing

the patient’s responsibility to show respect and consideration to others, and the MTF’s

authority to respond to the abusive or disruptive behavior.

2.19.4.2.3. If the active duty service member’s misconduct continues, ask the

member’s command authority to arrange security police escort when the member is

seeking medical or dental care. Definitive administrative or punitive action is a military

command issue.

2.19.4.3. When an active duty family member enrollee engages in disruptive behavior, the

MTF commander or director may:

2.19.4.3.1. Arrange a discussion between a senior hospital leader and the beneficiary,

with the sponsor present, to dissuade future disruptive behavior and describe potential

consequences.

2.19.4.3.2. With the active duty family member’s consent, empanel the family member

to a network provider, ensuring that the TRICARE contractor is informed of the

disruptive issue. Note: When an active duty family member is empaneled to the

network, if network empanelment is unable to accommodate, the MTF must empanel

the beneficiary to a MTF primary care manager unless the family member enrollee

elects TRICARE Select.

2.19.4.3.3. Issue a warning letter, in accordance with written MTF policy, conveying

the beneficiary's responsibility to uphold appropriate behavior including respect and

consideration to other patients and staff in accordance with DoDI 6000.14.

2.19.4.3.4. Ask the installation commander, or designee, to bar the active duty family

member from base under 18 USC § 1382. In some instances, an installation bar letter

may permit an active duty family member limited access to base for medical care; in

such cases, a military police escort may be required.

2.19.4.3.5. When the active duty family member’s disruptive behavior amounts to

criminal activity, in consultation with the base Staff Judge Advocate, seek to have the

family member prosecuted.

2.19.4.4. When confronted with disruptive behavior by a retiree, a retiree’s family

member, or a TRICARE Plus enrollee, the MTF commander or director has the same

options as with an active duty family member enrollee with a notable addition: the MTF

commander or director may involuntarily transfer the individual’s routine direct care and

access to ancillary services to a site outside the MTF. In this case the MTF commander or

26 AFMAN41-210 10 SEPTEMBER 2019

director will make efforts, in coordination with the TRICARE contractor, to find an

accepting network primary care manager. The TRICARE contractor and network primary

care manager must be made aware of past disruptive behavior. A coordinated handoff of

care to the network healthcare team is necessary to avoid any appearance of patient

abandonment. Should obtaining a network primary care manager prove impossible, self-

managed health care using TRICARE Select is likely the beneficiary's only TRICARE

option. For those TRICARE Plan and Medicare ineligible (a small minority of TRICARE

Plus enrollees) with no other health insurance, finding an accepting primary care manager

may be improbable; nonetheless if warranted, the MTF commander or director may transfer

empanelment of a TRICARE Plus beneficiary without other insurance to a network

provider for routine care and ancillary services.

2.19.4.5. Care providers must document patients’ abusive behavior. Commanders must

document actions taken to mitigate poor behavior. Transferring care to the network for

routine care and ancillary services is not to be used in an arbitrary or capricious manner,

such as for an argumentative patient or for patients not compliant with the treatment team

recommendations. It must be a compelling situation where the welfare and safety of the

patients or staff is seriously threatened. Additionally, if the patient has a history of, or is

exhibiting actions that may be due to mental illness or neurological impairment, the MTF

must manage these circumstances as a medical matter. MTF commanders and directors

should also notify leadership at other multi-service markets for the potential of a seriously

threatening patient who may seek care in their facilities.

2.19.5. MTFs with current capacity to provide primary care services to additional patients may

reassign TRICARE Prime beneficiaries from network primary care managers to MTF primary

care managers when beneficiaries live within a 30-minute drive time of the MTF.

2.19.5.1. When recapturing network Prime enrollees, MTF commanders or directors shall

recapture AD family members first and retiree beneficiaries second. (T-1). An exception

to this requirement are beneficiaries who require a primary care manager with a skillset

unavailable at the MTF, or there are strong continuity of care reasons against changing the

primary care manager.

2.19.5.2. Involuntary recapture campaigns must include communication with the

beneficiaries, multi-service market, if applicable, local elected officials, public affairs

officials, the TRICARE regional office, and the managed care support contracts. (T-1).

See “Enrollments” on Air Force Medical Operations Agency (AFMOA) Health Benefits

Knowledge Exchange (Kx) for best practices on conducting involuntary recapture

campaigns. https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

2.20. Sexual Dysfunctions, Inadequacies, or Paraphilic Disorders Treatment. For benefit

guidelines and instructions reference TRICARE Policy Manual 6010.60-M, Chapter 4, Section

16.1, Intersex Surgery.

2.20.1. Surgical procedures related to gender dysphoria may be provided within a MTF if there

is a provider appropriately credentialed, trained, current and privileged to perform the

procedure. Requests for surgery related to gender dysphoria for active duty must utilize the

Supplemental Health Care Program waiver process, in accordance with current Defense Health

Agency policy. (T-1). Patient travel may be authorized for patients who are referred to the Air

AFMAN41-210 10 SEPTEMBER 2019 27

Force Medical Multi-Disciplinary Team at the Wilford Hall Ambulatory Surgical Center in

San Antonio, TX for evaluation.

2.20.2. The patient must have appropriate endorsement from the Air Force Medical Multi-

Disciplinary Team and their unit commander. (T-1). Appropriate rules for billing and duty

status apply depending on the type of surgery being provided. Refer to AFI 44-102, for rules

on elective care and cosmetic care.

28 AFMAN41-210 10 SEPTEMBER 2019

Chapter 3

TRICARE OPERATIONS

Section 3A—Access to Care Guidance

3.1. Access to Care Standards.

3.1.1. Access to care for beneficiaries is a top priority for the MHS. All enrolled beneficiaries

regardless of their location, must be afforded access to care according to the standards

published in Health Affairs Policy 11-005. (T-0). See AFI 44-176, for additional information

and DHA IPM 18-001, Standard Appointing Processes, Procedures, Hours of Operation,

Productivity, Performance Measures and Appointment Types in Primary, Specialty, and

Behavioral Health Care in Medical Treatment Facilities (MTFs).

Section 3B—Beneficiary Counseling and Assistance Coordinator

3.2. Beneficiary Counseling and Assistance Coordinator Position and Procedural

Information.

3.2.1. Beneficiary Counseling and Assistance Coordinators are mandated at each MTF and

TRICARE regional office. Beneficiary Counseling and Assistance Coordinators will execute

roles and responsibilities in performance of their duties as stated in DoDI 6015.23. (T-0).

Duties include:

3.2.1.1. Inputting beneficiary associated casework into the Assistance Reporting Tool.

3.2.1.2. Tracking, managing, referring categorizing, and documenting case workload in

the Assistance Reporting Tool. Any cases that need referral to a DHA Program Office (to

DHA or a TRICARE regional office) must be sent via the Assistance Reporting Tool.

Assistance Reporting Tool credentials are requested by e-mailing

dha.ncr.comm.mbx.bcacdca[email protected] .

3.2.2. In the event of system connectivity issues, MTF personnel are encouraged to create and

utilize a temporary internal tracking mechanism. MTFs shall move information from their

internal tracking tool to the Assistance Reporting Tool when the tool is once again operational.

(T-2). For training, visit https://mhs.health.mil/customerservicecommunity/.

Section 3C—Debt Collection Assistance Officer

3.3. Debt Collection Assistance Officer Position and Procedural Information.

3.3.1. Debt Collection Assistance Officers are mandated at each MTF and TRICARE regional

office. Debt Collection Assistance Officers will execute roles and responsibilities in

performance of duties as stated in DoDI 6015.23. (T-0).

3.3.2. TRICARE Prime Remote members may contact DHA Great Lakes Debt Collection

Assistance Officer Representative at 1-(888)-647-6676 for assistance with debt collection

issues related to line-of-duty determinations; otherwise, members should work with the

appropriate regional managed care support contractor first.

AFMAN41-210 10 SEPTEMBER 2019 29

3.3.3. Beneficiary Counseling and Assistance Coordinator - Debt Collection Assistance

Officer Directory. Debt Collection Assistance Officers should ensure that contact information

is accurately reflected in the online public Beneficiary Counseling and Assistance Coordinator

- Debt Collection Assistance Officer directory found on the TRICARE website at

(http://www.tricare.mil/bcacdcao/). Changes and updates should be forwarded to the

TRICARE regional office.

Section 3D—Service Change Requests

3.4. Changes in Clinical Services. DoDI 6015.23 provides that the Secretaries of the Military

Departments and the Director, DHA, act on requests for changes in clinical services at MTFs as

recommended by respective military command authorities. Headquarters Air Force (HAF)

Mission Directive 1-48, The Air Force Surgeon General (AF/SG), states that the Secretary of the

Air Force further delegated authority to AF/SG to implement policy, assign responsibilities, and

prescribe procedures on provisions of care in the delivery of health care at MTFs pursuant to DoDI

6015.23. Per HAF Mission Directive 1-24, Assistant Secretary of the Air Force Manpower and

Reserve Affairs (SAF/MR) retains Secretarial oversight responsibility for all aspects of the Air

Force Active Duty, Reserve, and Auxiliary Component Affairs concerning health program benefits

and entitlements, to include those authorities delegated directly to the AF/SG. Thus, all service

change requests are coordinated with AF/SG, SAF/MR, and DHA before they are approved. (T-

1). Congressional reporting is required in accordance with NDAA 2019, Section 711, in the

interest of maintaining a positive relationship with members of the community and Congress, the

Congressional and Public Affairs office (AF/SGL) should be included in the process to provide

guidance.

3.4.1. MTFs will submit written request packages, already coordinated with their TRICARE

regional offices and MAJCOM command surgeon to Air Force Medical Readiness Agency

(AFMRA). AFMRA will then prepare requests and coordinate the package for AF/SG,

SAF/MR, and DHA approval. (T-0).

3.4.1.1. Permanent changes in services that significantly affect the current annual volume

of care provided to one or more categories of beneficiaries at a MTF for one or multiple

specialty or ancillary service(s).

3.4.1.2. Changes that impact users in a way that may stimulate local public or

congressional objections.

3.4.1.3. Temporary closures of services that are projected to last 90 days or more, or for

an indefinite period.

3.4.1.4. Changes in enrollment that result in the recapture or disengagement of 400 or more

beneficiaries in a single disengagement or recapture campaign or over a 1 year period.

3.4.2. MAJCOM command surgeons, AFMOA/SGAT, and MTF operational and resource

planners should include projected changes in services in their strategic planning documents

such as strategic plans, business plans, and/or strategic resourcing portfolios. Notify

AFMOA/SGAT as soon as possible of any projected changes in service, keeping in mind the

various planning cycles involved in accommodating changes. The planning cycle is at least

three fiscal years to facility modifications that involve major construction projects, at least two

years for manpower and financial resources, and at least twelve months for personnel

30 AFMAN41-210 10 SEPTEMBER 2019

assignments. The content and submission requirements for change in service requests may

vary depending on impact and cause of the proposed change.

3.4.2.1. Change in service requests shall include information as outlined below and must

arrive at AF/SG at least six months prior to the proposed effective date when the change

involves significant downgrading or upgrading in level of services. (T-2). This includes

downgrading from hospital to clinic, permanent closure of services, and adding a service

which has been previously unavailable at the facility. MTFs should not assume their

request will be approved.

3.4.2.2. Abbreviated requests or notifications may be submitted for any changes in service

which result in minor changes in type of services (such as discontinuing a subspecialty

service) or for any changes resulting from circumstances beyond the control of the

MAJCOM command surgeon, AFMOA/SGAT, or the MTF. This includes actions due to

resource management decisions, economic analyses for Military Construction Projects, and

for situations described below. Abbreviated requests or notifications should be coordinated

through respective MAJCOM command surgeons and AFMOA/SGAT, with information

copies sent to TRICARE regional offices, and should arrive at AF/SG not later than 90

days prior to the effective date of the change.

3.4.2.3. If a temporary change in services occurs as a result of sudden staffing changes or

reassignments, equipment breakdowns, supply shortages, or other unexpected

circumstance, immediately notify the TRICARE regional office, command surgeon,

AFMOA/SGAT, and prepare an abbreviated package as soon as possible but arriving at

AF/SG no later than 30 days following the change. If the change eventually results in a

permanent closure of services, a more detailed package is required within 90 days of the

original closure.

3.4.2.4. Changes in services which are made under the following circumstances do not

require prior notification to AF/SG and SAF/MR approval, but the MTF commander or

director shall report the change in services to the chain of command (T-1):

3.4.2.4.1. A facility rendered structurally unsound by a natural disaster.

3.4.2.4.2. A change in a Status of Forces Agreement.

3.4.2.4.3. An initial response to an emergency deployment of healthcare personnel.

3.4.2.4.4. A change in local Force Protection Condition.

3.4.3. The service change request will include or address the following information:

3.4.3.1. Name and location of the facility.

3.4.3.2. Type of change in service and, if applicable, the Medical Expense and

Performance Reporting System specialty area.

3.4.3.3. Proposed effective date of the change and/or the estimated duration of the change.

3.4.3.4. Reason or Justification for the change.

3.4.3.5. Summary of the impact on beneficiaries, including access and quality of

alternatives and difference in cost, if any (e.g., estimated increase or decrease in out-of-

pocket expenses).

AFMAN41-210 10 SEPTEMBER 2019 31

3.4.3.6. Evidence of briefing and feedback to wing commanders and/or line commanders

and beneficiary groups supported by MTF (such as retiree and veterans associations and

staff of congressional field offices), and concerns resolved or addressed by MTF; may

include beneficiary marketing and education plan in package.

3.4.3.7. Impact on readiness capability, including how training needs will be affected

and/or addressed to maintain technical and clinical skills and currency, knowledge, tasks

required for wartime, enhancement of a fit force, and improvements in force protection.

3.4.3.8. Description of how the change(s) is/are consistent with the overall health services

mission and strategy for the medical facility, MAJCOM command surgeon, and AFMOA,

Department of Defense (DoD) Health Services Region, Air Force, MHS, etc., including

implementation of new and innovative ways for promoting better health among

beneficiaries and the military community.

3.4.3.9. Estimated workload changes, by Medical Expense and Performance Reporting

System specialty area and beneficiary category, including number of non-availability

statements, beneficiary visits, admissions, bed days, and/or ancillary service work units.

Beneficiary categories should include Active Duty (AD), non-TRICARE eligible, and

TRICARE-eligible, with the latter broken down into AD dependents, and non-AD

dependents.

3.4.3.10. Projected savings (or cost) to the government, by fiscal year, resulting from the

change, including operations and maintenance funds (including civilian staffing), military

personnel, impact from estimated bid price adjustment, and military construction project

costs, if applicable. Submit all calculations used in determining final estimates, including

methodology for both full and marginal cost estimates.

3.4.3.11. Net manpower, equipment, and facilities resources resulting from the proposed

change, and projected methodology for redistributing resources, if applicable; include how

surplus resources will be used in other functions or eliminated.

3.4.3.12. Analysis of alternative ways to provide care to the beneficiaries affected,

including projected increases in cost of each alternative, as well as, the financial

implications to the beneficiary. The analysis should include the following:

3.4.3.12.1. Quality and Utilization of Services: Provider qualifications, accreditation,

preventive measures, health outcomes, beneficiary satisfaction, and projected volume

and level of care based on beneficiary needs and/or referrals.

3.4.3.12.2. Cost: Government as well as beneficiary savings or costs.

3.4.3.12.3. Access: Availability of civilian or other federal healthcare providers in the

community, including options such as DoD/VA sharing, contracting, TRICARE

resource sharing or resource support agreements.

3.4.3.12.4. Other: Local market factors which may influence the use of alternatives

such as quality, cost, access and other unique factors specific to the MTF, local

community, or region that could potentially generate future benefits or problems

resulting from the requested service change.

32 AFMAN41-210 10 SEPTEMBER 2019

3.4.3.12.5. Projected impact in terms of increased reliance on TRICARE managed care

support contractor and/or Medicare providers in the service area in which the MTF is

located.

3.4.3.12.6. Long-term costs and savings in infrastructure such as information systems

requirements, contracts, and facilities (including minor construction, major repair or

military construction projects) currently underway, recently completed, and/or

planned.

3.4.3.12.7. Explanation of how the change is/is not consistent with the MTF strategic

resourcing portfolio, business plan, goals and objectives, etc.

3.4.3.13. TRICARE regional office input may include, but is not limited to:

3.4.3.13.1. How the change is/is not consistent with the TRICARE regional office

business plan/strategic plan/regional health plan, including comparison with any

regional alternatives or initiatives, particularly those involving the TRICARE managed

care support contractor.

3.4.3.13.2. Impact on the managed care support contractor, and if available, the net

negative or positive cost impact to the region and/or another DoD MTF, particularly in

overlapping prime service areas, also known as the areas in which the contractor offers

enrollment in TRICARE Prime.

3.4.3.13.3. Coordination/feedback from other Services, MAJCOM command

surgeons, and/or AFMOA/SGAT, particularly if impacting graduate medical education

programs.

3.4.3.13.4. Recommendations, including estimated timeline.

3.4.3.14. MAJCOM command surgeons must submit evidence of coordination with

MAJCOM commanders (through MAJCOM Plans and Programs offices) and shall include

in their evaluation (T-1):

3.4.3.14.1. Impact on readiness baseline and how MAJCOM command surgeon or

AFMOA/SGAT proposes to make any necessary changes to operational mission within

the command to accommodate change.

3.4.3.14.2. Validation of military personnel disposition (e.g., if Military Personnel

savings are expected and, if applicable, how MAJCOM command surgeon or Air Force

Medical Operations Agency, Manpower Division (AFMOA/SGAP) proposes to

redistribute resources in accordance with projected limits to downsizing force in

accordance with Air Force Medical Service (AFMS) rightsizing efforts, Base

Realignment and Closure plans, and other factors).

3.4.3.14.3. Explanation of how the change is/is not consistent with the MAJCOM

command surgeon’s business plan, strategic plan, or strategic resourcing portfolio.

AFMAN41-210 10 SEPTEMBER 2019 33

Section 3E—Referral Management Program

3.5. Referral Management Program.

3.5.1. Guidance, Policy, and information regarding referral management business rules can be

found in AFI 44-176. Best practices regarding referral management can be found on the Air

Force Medical Service (AFMS) Kx Referral Management website at

https://kx.health.mil/kj/kx8/AccesstoCare/Pages/referral_management.aspx.

3.5.2. Support to Geographically Separated Units (GSU)/TRICARE Prime Remote enrollees.

3.5.2.1. GSU members are usually enrolled to a civilian Primary Care Manager through

the TRICARE Prime Remote program. When a TRICARE Prime Remote member’s

medical condition warrants referral to a MTF for either administrative reasons (e.g., Line

of Duty, Medical Evaluation Board, etc.) or specialty care, the MTF becomes clinically

responsible for that patient. If the MTF subsequently refers the patient to the local network,

while maintaining clinical oversight of the patient’s care, the approval and authorization

process rests with the referring MTF. Under no circumstance will the Specified

Authorization Staff at the DHA-Great Lakes be asked to place an authorization into the

system for a TRICARE Prime Remote enrolled patient when a MTF initiated the referral.

If the patient’s clinical needs exceed the MTF’s oversight capability, care management is

returned to the civilian Primary Care Manager through the Specified Authorization Staff.

These same guidelines apply to RC personnel referred to MTFs for medical and

administrative support.

Section 3F—Medical In/Out-Processing Program

3.6. Medical In/Out-Processing Program Overview.

3.6.1. Air Force medical units will apprise all beneficiaries, in particular military service

members, of their healthcare benefits as they move from one assignment to another.

Specifically, members must be informed of the scope of their benefits; how to access healthcare

in their local community; how to access healthcare while away from home or enroute to a new

duty station; and how to resolve problems related to medical care and access during this

transitional period, should they arise. (T-0). Reference DoDI 6000.14.

3.6.2. Medical In/Out-Processing Program Roles and Responsibilities.

3.6.2.1. MTF Commanders or Directors. MTF commanders or directors will establish

medical in/out-processing programs designed to ensure enrolled beneficiaries have a basic

understanding of their individual health benefits, the MTF’s capabilities, and a basic

overview of preventative health programs available to patients. (T-0). Reference DoDI

6000.14.

3.6.2.2. MTF commanders or directors will ensure MTF staff members are familiar with

the typical subject issues and topics discussed at in/out-processing briefings. (T-0).

Reference DoDI 6000.14.

3.6.2.3. MTF staff members should have a basic understanding of TRICARE benefit

options and be able to clearly communicate these options to beneficiaries when required –

or at least know to refer patients who have TRICARE enrollment or general health benefits

34 AFMAN41-210 10 SEPTEMBER 2019

questions to the appropriate office to obtain further information. Health benefits briefings

may be combined with other installation information briefings normally provided to

arriving and departing service members. Although not specifically limited as an exclusive

TRICARE Operations and Patient Administration obligation, generally, MTF staff

members assigned to this office are responsible for providing the healthcare benefits

portion of each in/out-processing function.

3.7. In-processing Requirements. At a minimum, the following information or procedures must

be accomplished with, or briefed to, each sponsor during the in-processing briefing(s) by

TRICARE Operations and Patient Administration staff (T-3):

3.7.1. TRICARE enrollment options.

3.7.2. Choosing a new primary care manager and how to contact their provider or clinical

support team.

3.7.3. How to change their primary care manager at the new location.

3.7.4. Benefits of enrolling in TRICARE Prime, including Point of Service option for Non AD

Beneficiaries.

3.7.5. Local polices on TRICARE Prime enrollment and CHCS registration data collection.

3.7.6. How to enroll family members in the dental plan.

3.7.7. MTF/TRICARE regional office/managed care support contractor/TRICARE service

points of contact.

3.7.8. Exceptional Family Member Program with a brief description of each of the MTF

partner programs that support Exceptional Family Member Program, Exceptional Family

Member Program-Medical and the Family Member Relocation Clearance processes.

3.7.9. Family Advocacy Program.

3.7.10. How to schedule/cancel appointments.

3.7.11. Out of area care procedures.

3.7.12. Services available at local MTF (s).

3.7.13. How to access services not available at the local MTF and after hours.

3.7.14. Services available in the network.

3.7.15. AFMS health record custody policy.

3.7.16. Mental Health.

3.7.17. Local prescription services.

3.7.18. Personnel Reliability Assurance Program, Presidential Support Program, and other

sensitive duties program overview.

3.7.19. How to file a civilian medical or dental claim.

3.7.20. Contact information for the Beneficiary Counseling and Assistance Coordinator/Debt

Collection Assistance Officer.

3.7.21. Co-payments and cost-share/deductible fees for care outside the direct care system.

AFMAN41-210 10 SEPTEMBER 2019 35

3.7.22. How to enroll or update TRICARE Online member profiles to gaining MTF.

3.7.23. Collect any medical or dental records that the member may be carrying and return to

the MTF records room or primary care management team for which the beneficiary is or will

be assigned.

3.7.24. Procedures for participation in Secure Messaging, if available at the MTF.

3.8. Out-processing Requirements. At a minimum, the following information or procedures

must be accomplished with, or be briefed to, each sponsor during the out-processing

appointment(s) by TRICARE Operations and Patient Administration staff (T-3):

3.8.1. Ensure all laboratory and radiology results are scanned/uploaded into in the individual’s

electronic health record within 0-5 business days prior to final out-processing appointment for

Permanent Change of Station (PCS), separation or retirement.

3.8.1.1. For individuals enrolled in Exceptional Family Member Program, or navigating

the Family Member Relocation Program/Process, scan/upload medical documents into

their electronic health record prior to the screening as required in accordance with AFI 40-

701, Medical Support to Family Member Relocation and Exceptional Family Member

Program (EFMP).

3.8.2. The DoD and AFMS health records custody and control policies.

3.8.3. The process required to file medical claims for care while in transit.

3.8.4. The process required to schedule appointments in transit.

3.8.5. The process required to locate a MTF at the next assignment.

3.8.6. The process required to obtain prescription services while in transit.

3.8.7. The process required to transfer/change the Primary Care Manager to a new MTF.

3.8.8. The process required to avoid point of service charges while in transit.

3.8.9. How to obtain emergency care and the patient responsibilities for contacting her/his

Primary Care Manager.

3.9. Limited Capability Out-processing. If a member is going to a medical facility without

access to Composite Healthcare System (CHCS)/Health Artifact and Image Management Solution

(HAIMS)/Armed Forces Health Longitudinal Technology Application (AHLTA) or MHS

GENESIS (such as geographically separated or remote locations, recruiters not near an installation,

or Navy members going to a ship, etc.), all electronic health records will be printed and filed in

the hard copy record. (T-0). If the member is moving to a traditional location/MTF, only medical

records created prior to the implementation of AHLTA (2006) need to be filed in the hard copy

record and forwarded to the gaining MTF.

3.10. Retirement/Separation Out-processing. For AD Service Treatment Record disposition

(member is separating or retiring), the Air Force Service Treatment Record Processing Center

needs all hardcopy encounters/records not captured in AHLTA. AHLTA Web Print will capture

all electronic medical records documented. For Non-Service Treatment Record disposition, all

records are required to be printed in hard copy format, as the records are legally required to be

complete upon arrival at the National Processing Records Center. (T-0). Reference DoDI 6040.45,

DoD Health Record Life Cycle Management.

36 AFMAN41-210 10 SEPTEMBER 2019

Section 3G—External Resource Sharing Agreements

3.11. External Resource Sharing Agreement.

3.11.1. MTF Responsibilities. MTFs seeking External Resource Sharing Agreements must

coordinate approval with AFMOA/SGAT prior to signing. (T-1).

3.11.2. MTFs will request a child Defense Medical Information System Identifier through the

Air Force Defense Medical Information System ID coordinator (AF/SGY) for new External

Resource Sharing Agreements within 30 days of being signed by the TRICARE regional office

director. (T-1).

3.11.2.1. MTFs will capture all workload performed under an External Resource Sharing

Agreement in the Defense Medical Information System ID set up for the External Resource

Sharing Agreement. (T-1).

3.11.2.2. Workload performed under a Training Affiliation Agreement shall not be

captured under an External Resource Sharing Agreement Defense Medical Information

System ID. (T-1).

3.11.3. MTFs will forward a copy of new External Resource Sharing Agreements to

AFMOA/SGAT within 30 days of being signed by the TRICARE regional office director. (T-

2).

3.11.4. MTFs will internally review all External Resource Sharing Agreements annually, and

document the review locally. (T-1). External Resource Sharing Agreements that are no longer

active and not anticipated to become active before the next annual review should be terminated

in accordance with the External Resource Sharing Agreement’s terms.

3.11.5. MTF commanders or directors may only authorize Medicare dual eligible beneficiaries

to be seen under an External Resource Sharing Agreements for care that is a non-covered

benefit under Medicare. (T-1).

AFMAN41-210 10 SEPTEMBER 2019 37

Chapter 4

PATIENT ADMINISTRATION FUNCTIONS

Section 4A—Legal Aspects of Protected Health Information (PHI), Release of Information

and Patient Self-Determination

4.1. Laws and Provisions Affecting Disclosure of Medical Information.

4.1.1. Privacy Act of 1974.

4.1.1.1. Medical records are maintained within a system of records protected by the

Privacy Act. Disclosure to third parties is prohibited, except pursuant to the written

authorization of the individual to whom the record pertains or in specified limited

circumstances as outlined in the Privacy Act (as implemented by Air Force Instruction

(AFI) 33-332, Air Force Privacy and Civil Liberties Program), and the HIPAA Privacy

Rule (as implemented by AFPD 41-2, Medical Support and AFI 41-200).

4.1.1.2. Refer to AFI 41-200 for guidance on the collection, safeguarding, use,

maintenance, access, amendment and disclosure of information. AFI 41-200 explains

policy on access, disclosure, time periods, denial authority, judicial sanctions, and

accounting of disclosures.

4.1.1.3. DD Form 2005, Privacy Act Statement - Healthcare Records, eliminates the need

for a separate Privacy Act statement for each medical, dental or related document requiring

individual identifying information. The DD Form 2005 is not a consent form. It serves as

evidence that, as prescribed by the Privacy Act, the individual was informed of the purpose

and uses of the information collected and was advised of rights and obligations with respect

to supplying the data. The patient’s signature is not mandatory. When the Privacy Act

statement is printed on the reverse of AF Form 560, Authorization and Treatment

Statement, or on the record folder, the DD Form 2005 is not required.

4.1.2. Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Records. Alcohol and

Drug Abuse Prevention Program information collected and maintained as part of Alcohol and

Drug Abuse Prevention treatment or aftercare services are maintained in accordance with AFI

44-121, Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program and AFI 44-

172, Mental Health. These records are protected from public disclosure and afforded special

protections.

4.1.3. Freedom of Information Act (FOIA). See DoDM 5400.07, AFMAN 33-302, Freedom

of Information Act Program, for specific guidance and procedures related to the release of

information from health records.

4.1.4. HIPAA. Reference AFI 41-200.

4.1.5. Provisions Regarding the Release of Mental Health Information. Mental health

information will be protected in accordance with AFI 33-332, AFI 41-200, and AFI 44-172.

4.1.6. State Laws, Reporting Guidance for Medical Personnel, and Medical Documentation of

Restricted Reports.

38 AFMAN41-210 10 SEPTEMBER 2019

4.1.6.1. Providers must consult the supporting medical law consultant or Staff Judge

Advocate’s office when child abuse, domestic abuse, or sexual assault is evident or

suspected. (T-3).

4.1.6.2. Some states require medical providers to report to civilian authorities in situations

addressed by DoD policies, to include those DoD polices that provide for restricted

reporting. Mandatory reporting laws are typically based on the law of the state where care

is currently being provided and not to the state of licensure. However, while working in a

MTF, follow DoD and AF policy. If federal law, DoD policy or AF policy require

reporting, follow the provisions in such policy. However, any state law or regulation that

would require a healthcare professional to disclose the PII or PHI of an adult victim or

alleged perpetrator of sexual assault to law enforcement shall not apply, except when

reporting is necessary to prevent or mitigate a serious and imminent threat to health and

safety.

4.1.6.3. Medical record documentation under restricted reporting must contain sufficient

information to allow for continuity of care and coding. (T-0). The following wording in

bold type should be placed at the top of each notation in the approved electronic health

record or paper record: "Restricted from disclosure unless and until determined to be

releasable by the MTF commander, director or designee. Do not release without

specific patient authorization or as specifically authorized by federal law or DoD or

Air Force policy." Electronic records in AHLTA may also be secured via a "break the

glass," (means for a person who does not have access privileges to certain information to

gain access when necessary) or disclosure function with the above notation in place. This

function highlights those entries as restricted and prompts additional review prior to release

or electronic review.

4.2. Health Record Custody and Control.

4.2.1. Each MTF will develop policies and procedures for defining levels of access to health

information by individuals or groups of individuals (work centers) based on requirements in

fulfillment of assigned duties. (T-1). At a minimum, guidance should address:

4.2.1.1. Standardized matrix for evaluating specific roles against access requirements.

4.2.1.2. Review and approval process, to include approval authority.

4.2.1.3. Procedures for periodically validating access requirements.

4.2.1.4. Termination of access procedures.

4.2.2. Maintaining custody and control of original medical, dental, and inpatient records.

4.2.2.1. Take necessary precautions to avoid compromise of medical information during

the movement of the record inside and outside the MTF.

4.2.2.2. Original health records are not to be released to anyone outside the MTF without

specific and verifiable operational mission related, legal or medical necessity requirements.

4.2.2.3. MTF commander or director approval and authorization is required for unescorted

access to medical records areas. Written authorization memorandum must be posted near

each entrance for ready reference. (T-2). If commander’s written authorization is required

prior to electronic access identification card swipe activation, individuals with

AFMAN41-210 10 SEPTEMBER 2019 39

identification card swipe access do not need to be identified on the posted listing. This

does not apply to keypad access due to the potential for security compromise.

4.2.3. Establish written procedures to ensure highly sensitive records and sensitive medical

information are safeguarded. This includes safeguarding x-rays and fetal monitoring strips.

Examples of highly sensitive records include mental health records, substance abuse treatment

records, records related to sexual assault, records related to child or adult abuse, and records

relevant to a claim or suit against the United States. To protect the sensitive nature of the

information, medical records staff will only release Mental Health notes that are marked

sensitive with approval from the treating mental health provider. Consults marked sensitive

will be released only after review and approval by the primary care provider (or mental health

provider, if the patient is being treated in mental health).

4.2.4. Sequestering Health Records. Sequestering a health record is the storage and securing

of a health record separate from other health records for added security or for legal purposes.

The MTF may sequester the original medical record or a certified copy when the situation

warrants. A notice should be placed on the original record to ensure personnel do not allow

the patient to hand-carry the record while there is an active claim or litigation. If a certified

copy is made for sequestering, return the original record to the file room and suspense and

label it for periodic updates. Records will be sequestered under the following conditions (T-

2):

4.2.4.1. When an administrative claim or lawsuit against the government has been filed.

4.2.4.2. When a patient has tried to tamper, alter or illegally remove a record from the

facility.

4.2.4.3. When a request is received from an attorney under circumstances indicating claim

or law suit is being considered.

4.2.4.4. When an Inspector General (IG), congressional inquiry or investigation has been

initiated and when the medical record is relevant to an IG or congressional inquiry/

investigation.

4.2.4.5. When the record becomes relevant to an Air Force Office of Special Investigation

(AFOSI) or Security Forces investigation. Annotate sequestered record form with the

AFOSI/Security Forces agent’s name and case number for annual review process. Contact

the medical law consultant, Staff Judge Advocate or HIPAA privacy officer for questions.

4.2.4.5.1. Investigative agencies, such as AFSOI have the authority to request a delay

in disclosure reporting. The individual’s right to receive an accounting of disclosures

to the law enforcement may be temporarily suspended if the agency or official indicates

that such an accounting would impede the agency‘s activities. Verbal requests for

suspension shall not exceed 30 days; suspensions beyond 30 days require a written

request. (T-2). Account for the disclosure per AFI 41-200 if no request for temporary

suspension is made or upon the expiration of a temporary suspension.

4.2.4.5.2. Address military Service Member agents of the AFOSI as “Special Agent,”

followed by their last name. Refrain from addressing a military Service Member agent

using the member’s military rank.

40 AFMAN41-210 10 SEPTEMBER 2019

4.2.4.6. For purposes of safety or mishap investigations, the MTF Release of Information

Office will facilitate the appropriate collection of medical and/or dental records for

disclosure to a Safety Investigation Board and/or Accident Investigation Board.

4.2.4.6.1. Original hard copy paper medical and dental records of persons of interest

in a safety investigation must be immediately sealed in envelopes and sequestered in a

secure location. (T-3). Provide a copy of the original records to the Interim Safety

Board Medical Officer as soon as one is appointed.

4.2.4.6.2. Records that are only maintained in electronic format will need to be printed

or downloaded as encrypted electronic files (CD-ROM, USB drive, etc.), if the

investigating medical officer(s) will not have access to the electronic record systems

(AHLTA, CHCS, HAIMS, or other approved electronic health record). (T-2). Seal

these in a separate envelope and also provide to the Safety Investigation Board.

4.2.4.6.3. During the investigation, the Safety Investigation Board or Accident

Investigation Board may periodically request an update of any medical

records/documents related to the investigation and continuing care.

4.2.4.6.4. At the conclusion of the Safety Investigation Board and/or Accident

Investigation Board, all medical and dental records, including any electronic copies,

will be returned to the MTF Release of Information Office and handled in accordance

with Air Force document retention and destruction requirements.

4.2.4.7. It is the MTF commander’s or director’s responsibility (with advice from the

Quality Services Manager, medical law consultant, or Staff Judge Advocate) to establish

local operating instructions regarding sequestered medical records safekeeping policy and

procedure. At a minimum, the records will be kept in a separate, locked location, with

limited staff and patient access. If the patient is actively being treated at the MTF, copy

the original record for the outpatient records room and annotate on the jacket “Clinic

Copy.” Create the clinic copy in CHCS as a unique record type for tracking purposes in

the Medical Records Tracking module.

4.2.4.8. Place a cover sheet on the original medical record stating the record has been

sequestered. Maintain a separate file on why the record has been sequestered and the date

(or occurrence of an event) when the record should be reviewed to determine the need for

continued sequestering. Place a charge out, which details where the record is located, in

appropriate records room with statement that the record has been sequestered. If a clinic

copy is made, ensure that original documentation is forwarded to the sequestered file and

a copy is placed in the clinic copy.

4.2.4.9. Coordinate an annual review of sequestered records with the base legal office to

determine whether the records should continue to be sequestered. In addition, ensure that

records are reviewed prior to patient relocation to see if sequestering is still applicable. If

sequestering is still required, mail the outpatient records to the gaining MTF. Include a

cover letter stating the records are to be sequestered and an explanation of the

circumstances. The losing MTF will make a certified true copy of the record before

mailing. Maintain the copy until the claim or litigation is resolved and the base legal office

or Air Force Legal Operations Agency, Claims and Tort Litigation Division

(AFLOA/JACC) concurs.

AFMAN41-210 10 SEPTEMBER 2019 41

4.3. General Guidelines on Releasing Medical Information.

4.3.1. Original medical documents or records are not released to any non-federal government

agency, except in compliance with a valid court order or as otherwise required by law. Always

consult the medical law consultant or Staff Judge Advocate prior to releasing medical

information under these circumstances.

4.3.1.1. Documentation received via fax can be scanned into Health Artifact and Image

Management Solution (HAIMS) or other approved patient electronic health record.

4.3.1.2. The use of a fax machine to transmit provider’s orders is permissible. To verify

their authenticity, the provider should sign the orders prior to transmission. Reference AFI

44-102, for additional information. If the orders were not signed, do not carry them out

until the ordering provider verifies them. (T-1). Unless otherwise required by applicable

law or regulation, the faxed copy does not require countersignature.

4.3.1.3. Documentation transmitted on thermal paper will fade over time. If a fax machine

uses thermal paper, make a photocopy of the document and scan/upload into HAIMS or

approved electronic health record. Destroy the thermal paper document and photocopy

after scanning/uploading.

4.3.2. Health records may contain information from non-military sources. A patient can be

referred to a non-military source for ancillary, diagnostic care, and/or treatment.

Documentation from the non-military source that supports the diagnosis and treatment will be

scanned/uploaded into HAIMS or approved electronic health record. This documentation will

then become a part of the patient’s medical record and subsequent releases of information from

the patient’s record will include this information from non-military sources.

4.3.3. Special Handling of Medical Records.

4.3.3.1. Records of Newborns Released for Adoption. Take special care releasing

information from the records of newborns who have been released for adoption. Delete all

references to the child’s natural parents. Stamp or identify the newborn inpatient record

with the following statement, “Release of Information Restricted according to AFMAN

41-210, Chapter 4.” Do not forward AF Form 560, AF Form 565, Record of Inpatient

Treatment, SF 502, Medical Record - Narrative Summary (Clinical Resume), or SF 535,

Medical Record - Newborn in the outpatient record.

4.3.3.2. Radiographs, Radiographic Images or Film (also known as X-Ray). Generally,

only the provider’s paper document radiographic interpretation or analysis report is

provided to the requestor. The cost of producing this paper report is usually free, unless

repeated requests for the same document are submitted. Copies of actual radiographs,

sometimes referred to as, radiographic film, x-ray film or x-ray images, may be provided

upon specific request via hard copy or CD/DVD.

4.3.3.3. All provider social security numbers must be redacted from the health record

before issuing a copy. (T-0). This mandate applies to all forms of health records (including,

but not limited to, the outpatient medical, dental treatment, inpatient, and extended

ambulatory record). This policy applies to copies provided for any purpose or request,

including an individual’s request for copies of the member’s own health records. Original

medical records shall remain intact and unaltered. The original provider’s social security

42 AFMAN41-210 10 SEPTEMBER 2019

number must never be deleted from the original health record. (T-0). Other social security

numbers should be redacted when warranted.

4.3.3.4. All sponsor social security numbers must be redacted from the health record

before issuing a copy, unless the copy request is made by the actual sponsor for their own

record. (T-0). This mandate applies to all forms of health records (including, but not

limited to, the outpatient medical, dental treatment, inpatient, and extended ambulatory

record). This policy applies to copies provided for any purpose or request. Original

medical records shall remain intact and unaltered. The original sponsor social security

number must never be deleted from the original health record. (T-0). Other Social security

numbers should be redacted when warranted.

4.3.3.5. Prior to the release of information, the health record should be reviewed to ensure

that information pertaining to other individuals is not contained in the record.

4.3.3.5.1. Erroneously filed documents should be removed in accordance with

paragraph 5.3.

4.3.3.5.2. Information pertaining to other individuals (e.g., other family members,

Edinburgh Postnatal Depression Scale in infant record) should be considered for

redaction. Consult the servicing legal office.

4.3.3.6. If a MTF provides health records electronically (e.g., scanned copy in lieu of

paper), the MTF must use standardized nomenclature when naming the file. (T-3). This

will allow outside agencies and others, as applicable, to easily identify a beneficiary’s

treatment record. At a minimum, the file name should contain the following: the term

“Outpatient Record,” “Dental Record,” or “Inpatient Record” as applicable, last name of

the beneficiary, and date the copy was made, e.g., OUTPATIENT RECORD_ [SMITH]

_15MAR2010] .pdf.

4.3.3.7. Scan all correspondence, e.g., requests for PHI from the patient’s health insurance

company, state worker’s compensation agency, or federal and state disability agencies,

with an attached information release statement regarding the release of information into

HAIMS, Section III of the electronic health record repository or approved electronic health

record for permanent safekeeping.

4.3.3.8. Fees for copying. The MTF is permitted to charge a reasonable, cost-based fee

for responding to requests for copies of health records, as outlined in AFI 41-200.

4.3.3.8.1. If the patient requests a copy of the medical record and the copy request is

complete, provide the patient with copies at no charge.

4.3.3.8.2. Upon local approval of the MTF commander or director, the Release of

Information Office may charge beneficiaries or their agents/representatives, for

excessive and repeated personal requests for the same document or repeated requests

for partial or complete volume copies that have already been provided to the patient or

his representative, within the same 12-month period.

4.3.3.8.2.1. If the individual requests a copy of the PHI or agrees to a summary or

explanation of such information, the covered entity may impose a reasonable, cost-

based fee, provided that the fee includes only the cost of:

4.3.3.8.2.1.1. Labor for the PHI requested by the individual, whether in paper

AFMAN41-210 10 SEPTEMBER 2019 43

or electronic form;

4.3.3.8.2.1.2. Supplies for creating the paper copy or electronic media if the

individual requests that the electronic copy be provided on portable media; and

4.3.3.8.2.1.3. Preparing an explanation or summary of the PHI, if agreed to by

the individual.

4.3.3.8.3. Advance payments for information requests from insurance companies and

other agencies may be accepted. If the request is for a large volume or requires

extensive research, notify the requester of any additional charges.

4.3.3.8.3.1. If the payment is incorrect, inform the requesting agency that the

information is being provided even though the required fee (specify amount) has

not been paid, to avoid possible adverse effect to the patient. Advise the requester

to send payment promptly to the Medical Service Account office by check or

money order payable to the Treasurer of the United States.

4.3.3.8.4. Send payment to the Medical Service Account office with the completed

copy of the transmittal letter if correct payment is received with the request. If the

requested information cannot be obtained on the day the request is received, complete

only the required items and send the form and payment to the Medical Service Account

office before the ordinary close of business each day.

4.3.3.8.5. If prepayment is not made, use a locally developed form to identify and

request the fees. Prepare the form in three copies; send the original to the requester,

file the second copy in part 3 of the health record with the patient's signed authorization

for release of information, and forward the third copy to the RMO. When answering

requests for information on injury cases that appear to involve medical affirmative

claims action, create a fourth copy of the form and send it to the medical law consultant

or Staff Judge Advocate.

4.4. Patient Requests for Copies of Medical Records and Restrictions. This section outlines

the patient’s right to request copies of their PHI, including copies produced from paper-based and

electronic-based medical records, and their right to request restrictions on uses or disclosures of

their PHI IAW AFI 41-200. Note that a patient may also be a member of the MTF workforce, as

Active Duty (AD), Reservist, civilian, or contractor. MTF workforce members should not be

accessing health records systems to obtain copies of their own medical records. MTF workforce

members should request copies of medical records in the same manner as any other patient as

outlined in paragraph 4.4.5.

4.4.1. Patient or Authorized Representative: Information may be released directly to the

patient or to a representative they designate in writing. An abstract of a patient's relevant

medical history (or copies of pertinent pages of the record) may be furnished to the patient, or

authorized representative, when the patient departs on a temporary absence from home and

requires medical care while away. While AFI 41-200 provides conditions upon which a

covered entity may deny an individual access to their PHI, since medical records are contained

in Privacy Act systems of records, access is generally required. Consult with the medical law

consultant or Staff Judge Advocate prior to denying an individual access to their own medical

records.

44 AFMAN41-210 10 SEPTEMBER 2019

4.4.1.1. If a provider determines that direct disclosure to the patient could have an adverse

effect on either the physical or mental health, safety, or welfare of the individual, or other

persons with whom the patient may have contact, the disclosure will be made to a

healthcare provider named by the individual, or to a person qualified to make psychiatric

or mental health determinations.

4.4.2. Provide patients or their designated representatives’ access to their health records upon

written request. The original record is always retained at the MTF, but copies will be provided

if requested. Per HIPAA and AFI 41-200, process copy requests within 30 days of receipt of

the DD Form 2870, Authorization for Disclosure of Medical or Dental Information, or other

written request. If, however, the requested medical record copies cannot be provided within

30 days, contact the requestor in writing and inform them of the delay and when the records

will be available. Copy requests not completed by the 30th calendar day will be elevated to

the squadron commander for immediate explanation and resolution. (T-3).

4.4.2.1. Military healthcare providers are encouraged to discuss, with their patients, the

contents of their patients’ health records at least once a year. Providers should encourage

their patients to review the healthcare information stored in their medical record to ensure

all necessary documents are included in the record, including referral results from civilian

network providers.

4.4.2.2. Healthcare providers may recommend ways of disclosing health records other

than by direct patient access. On occasion, a healthcare provider may elect to disclose

information on specific diagnoses of terminal illness or psychiatric conditions to a patient’s

designated representative, and not directly to the patient, with the patient’s concurrence.

4.4.3. Urgent copy requests for referral appointments. If a patient requests to remove the

medical record from the medical facility, MTF personnel are required to inform the patient of

the DoD policy prohibiting patients from hand-carrying their record(s). Primary Care

Managers and/or referring MTF providers are responsible for ensuring that a patient has copies

of any necessary paperwork from the outpatient, inpatient, dental records, other paper or

electronic health record required to ensure adequate medical reference and continuity of care

between the MTF and the external provider or civilian medical facility. These copies are

provided free of charge. If a patient has not obtained the necessary documents for the referral

visit for an external MTF patient appointment, copy the pertinent section/document(s) and

provide the copy to the patient. Requests of this type must be expedited so the patient can

provide this information to the referral provider at the time of the appointment. (T-3). Unless

specifically requested by either the referring or accepting physician, do not copy the entire

medical or dental record. Copies of pertinent medical documents may also be faxed or mailed

from the MTF to the receiving provider or civilian medical facility provided the necessary

coordination with the external provider has been accomplished.

4.4.4. Urgent copy requests to meet short-notice or no-notice service member separations or

discharges resulting from accelerated Force Management related personnel action. When

informed or notified by an appropriate service separation or discharge authority of a service

member’s request to obtain a complete copy of the member’s Service Treatment Record to

meet expedited Force Management related separation or discharge installation out-processing

requirements, the MTF Release of Information office will immediately prioritize the request

above all other non-urgent, routine requests. The service member is required to complete the

AFMAN41-210 10 SEPTEMBER 2019 45

necessary record copy request, DD Form 2870, for submission to the MTF Release of

Information office.

4.4.5. Non-Urgent, Routine Copy Requests. Refer the patient to the appropriate Release of

Information office. Release of Information personnel will inform the patient of the average

MTF wait-time for non-urgent requests and should use DD Form 2870.

4.4.5.1. The timeline for such request are established in paragraph 4.4.2. The time

duration may be based upon a variety of factors, including, but not limited to the staffing,

the size of the individual record(s) or record portion(s) to be copied, the number of non-

urgent daily and weekly requests, the number of emergent and/or urgent daily and weekly

requests and the time it takes to redact Social Security Numbers. The staff assigned to the

Release of Information Office should keep their supervisors appraised on any current or

impending delays. Unforeseen delays can be documented by the leadership and affected

beneficiaries should be notified.

4.4.5.2. The patient can elect to receive their records by unencrypted/unsecured e-mail or

to another individual designated by the patient. Documentation of patient permission to

send and receive medical information via electronic communication should be maintained

in the medical records or tracked internally in a Release of Information tracking

binder/spreadsheet for future requests. Reference AFI 41-200, paragraph 7.6, for a

description of requirements.

4.4.6. General rules and individual state laws specify when a power of attorney is required.

Refer any questions about power of attorney to the medical law consultant or Staff Judge

Advocate.

4.4.7. Amendments to Erroneous Information. A patient has a right to request an amendment

to their medical record. The amendment must be granted if it is determined that the information

contained in the record created by the MHS is inaccurate or incomplete. (T-0). Refer to the

MTF’s HIPAA Privacy Officer or the Air Force Medical Operations Agency (AFMOA) Health

Information Compliance Team Kx website for information on this process

(https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx).

4.4.7.1. The MTF commander or director will appoint in writing the MTF HIPAA privacy

officer as the primary point of contact for all matters related to erroneously entered

information in AHLTA. (T-3).

4.4.7.1.1. The appointment letter can include language that the MTF HIPAA privacy

officer is the commander’s designee for purposes of signing the “Request for AHLTA

Legal Correction of Erroneous Data or Erroneous Personal Health Information”

memorandum (MTF Commander’s or Director’s Memorandum). This letter is required

for each AHLTA amendment submission.

4.4.7.2. The MTF HIPAA privacy officer will ensure that policies and procedures are

developed at the local level (e.g., Medical Group Instruction) to address patient requests

for amendment of PHI. (T-1).

4.4.7.3. In the event that erroneous information in an AHLTA record is discovered by

someone other than the patient (e.g., provider, Release of Information personnel), the same

process for correction as referenced in paragraph 4.4.7 should be followed.

46 AFMAN41-210 10 SEPTEMBER 2019

4.4.7.3.1. The MTF HIPAA privacy officer will act on any correction/amendment to

the record as soon as practicable, but no later than 30 business days after receiving it in

accordance with AFI 33-332. (T-1). If the MTF is unable to act on the amendment

within 30 days, the time may be extended for no more than an additional 30 days. This

may occur if the Medical Group (MDG) provides the patient with a written statement

of the reason for delay, and the date by which the amendment request will be completed

in accordance with AFI 41-200. (T-1).

4.5. Patient Rights (Reference DoDI 6000. 14). MTF staff must inform patients of their rights,

according to state law, to make decisions regarding their medical care. (T-0). This includes the

right to accept or refuse treatment and the right to prepare advance directives. An advance

directive is defined as a written instruction by the patient, in the form of what is commonly known

as a living will or a durable power of attorney for healthcare, recognized under state law (some

states require both) and related to the provision for such care when the patient is incapacitated.

Signed advance directives shall become a part of the patient’s medical record. (T-1).

4.5.1. Each MTF will establish and maintain written policies and procedures to implement

patients’ rights to make decisions concerning their medical care. (T-0). Ensure compliance

with state law (whether statutory or as recognized by the courts of the state) respecting advance

directives.

4.5.2. Each MTF will provide to all adult patients written information on their rights under the

host state’s law to make decisions concerning their medical care, including the right to execute

an advance directive. (T-0).

4.5.3. Document whether or not each patient has an advance directive. This information will

be documented on the AF Form 560 for inpatient care or the DD Form 2766, Adult Preventive

and Chronic Care Flowsheet for outpatient care, and on the automated cover sheet for

ambulatory procedure visit cases. (T-1). Note: Utilize the DD Form 2766 and/or DD Form

2882, Pediatric and Adolescent Preventive and Chronic Flowsheet or Tri-Service Workflow

Pediatric Alternate Input Method forms for all new records. See Chapter 5, Health Records

Management, paragraph 5.12.5 for more information regarding this DD form 2766. Provider

teams are encouraged to ensure comprehensive notes are placed within AHLTA or Essentris

(system for inpatient medical care) to document whether or not each patient has an advance

directive, however, the hard copy documentation shall remain available. (T-1).

4.5.4. Each MTF will provide for education of the staff and community on issues concerning

advance directives. (T-1).

4.5.5. Check with the servicing medical law consultant or installation Staff Judge Advocate

for further guidelines.

4.5.6. Military advance medical directives are exempt from any requirements of form,

substance, formality or recording required by state law. For example, if an Air Force member

has a military living will prepared in Florida, but then becomes severely injured in California,

the military living will is honored in California even though the document may not conform to

California Law.

AFMAN41-210 10 SEPTEMBER 2019 47

Section 4B—Patient Registration & Multiple Healthcare Eligibility

Note: Section 4B applies to the Legacy System, CHCS only. As MHS GENESIS implementation

efforts continue, additional information will be provided.

4.6. Patient Registration.

4.6.1. The Patient Administration function has direct oversight of MTF patient registration.

MTF clinical work centers such as the pharmacy, laboratory, and the emergency department,

require the ability to register patients in CHCS or approved electronic health record. To ensure

a balanced and responsible registration process throughout the MTF, Patient Administration

personnel, in partnership with CHCS Administrators and Information Management officials,

will provide user training and are the only MTF approval authorities authorized to grant

registration access and/or similar capabilities. (T-3). Requests for registration training should

be coordinated and approved by the flight superintendent or flight commander before

submitting requests to the MTF TRICARE OPERATIONS AND PATIENT

ADMINISTRATION Flight Commander, Patient Administration Officer, Systems or

Information Management Flight Commander.

4.6.2. Patient Administration officials will conduct periodic reviews of all MTF personnel

with registration capabilities to verify training requirements have been met and registration

capabilities remain valid. (T-3). Reference MHS, Patient Identity Management and

Registration Guidance.

4.6.3. When registering a patient for the first time, MTF personnel should obtain as much

information as possible without degrading medical care. At a minimum, the following patient

information must be captured (T-3):

4.6.3.1. Patient’s name (first, last & middle initial).

4.6.3.2. Sponsor’s name.

4.6.3.3. Sponsor’s Social security number.

4.6.3.4. Patient’s relationship code/family member prefix e.g., 20-Sponsor, 30-Spouse,

01-Child, etc.

4.6.3.5. Patient Category (e.g., F11/Active United States Air Force, A11/Active United

States Army, F31/Retired United States Air Force Service Member, M12/Marine Corps

RC Member, N41/AD Navy Family Member, etc.).

4.6.3.6. Patient’s date of birth.

4.6.3.7. Patient’s gender.

4.6.3.8. Patient’s Service (sponsor only).

4.6.3.9. Patient’s station/unit (sponsor only).

4.6.3.10. Patient’s rank (sponsor only).

4.6.3.11. Patient’s address & telephone contact information.

4.6.3.12. Organ donor declaration (yes, no, or unknown).

4.6.3.13. Third party health insurance information.

48 AFMAN41-210 10 SEPTEMBER 2019

4.6.3.14. MTF where medical record(s) are normally maintained.

4.6.3.15. Marital status (if full registration is used).

4.6.3.16. Race (if full registration is used).

4.6.3.17. Ethnicity (if full registration is used).

4.6.3.18. Individual Patient Social Security Number or available/authorized unique

“Person or Personal Identifier” (DoD Identification Number, Foreign Identification

Number, Temporary Identification Number, Individual Taxpayer Identification Number,

etc.).

4.6.3.18.1. Person or Personal Identifiers. Most patients treated in the AFMS possess

a Social Security Number. Individual identification using a person’s unique Social

Security Number provides a solid framework from which to build a personal eligibility

profile in Defense Enrollment Eligibility Reporting System (DEERS) and within the

MTF.

4.6.3.18.2. Social Security Numbers are considered Person or Personal Identifiers and

are used as the default numeric account number for which CHCS partly bases

individual identification. Some patients, however, may not possess a Social Security

Number for various reasons. Frequently, alternative Person or Personal Identifiers are

used to reduce the use of Social Security Numbers or identify patients as individuals

who may not possess a Social Security Number. There are multiple alternative Person

Identifiers issued, used, and/or created depending on the patient’s particular situation.

For more technical information on the use of personal identifiers refer to AFMOA Kx

Patient Registration Training located at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

4.6.3.19. Command Security if applicable, e.g., Personnel Reliability Assurance

Program/Presidential Support Program.

4.6.3.20. Active Flight Status (if patient is assigned to an active flight position). This is a

full registration demographic question and minimal full registration data must be available

to properly complete the registration for this category of patient. (T-2).

4.6.3.21. Length of Service (years).

4.6.4. The MHS, when feasible, will limit the use and display of Social Security Numbers

while migrating systems and business processes to use the DoD Identification Number. (T-0).

Reference DoDI 1000.30, Reduction of Social Security Number (SSN) Use Within DoD.

4.6.5. Registration Options. Please refer to the MHS, Patient Identity Management and

Registration Guidance for current, accurate and complete information on all registration

options. For best practices on registration see AFMOA Kx Patient Registration Training

located at https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

4.7. Patients with Multiple-Eligibility. Beneficiaries will only be registered one time on each

CHCS host according to their highest level of eligibility. (T-0) See MHS, Patient Identity

Management and Registration Guidance, for technical information.

AFMAN41-210 10 SEPTEMBER 2019 49

4.7.1. The TRICARE Operations and Patient Administration and systems offices must ensure

that all MTF staff members who possess registration capabilities are aware of the problems

associated with multi-eligible patients and other current patient identity problems. (T-1).

4.7.1.1. Providers and MTF staff must be aware of the potential problems associated with

dual or multiple-eligibility patients and how to implement corrective measures and

alternative processes to ensure the patient’s healthcare is properly documented. (T-1).

4.7.1.2. MTF TRICARE Operations and Patient Administration staff or system managers

are authorized to merge erroneous duplicate records by merging the alias record with the

surviving record using the Former Patient Name functionality within CHCS. An alias

record indicates that a record is also known or more familiar under another specified record.

A surviving record is the complete record remaining after the merge of duplicate records.

AHLTA changes must be processed in accordance with current MHS merge/unmerge

guidelines. (T-1). Reference Assistant Secretary of Defense for Health Affairs

Memorandum, Guidance for Requesting Correction of Erroneously Entered Information

in the Armed Services Longitudinal Health Technology Application.

4.7.1.3. Potential Duplicate Patient Report. Collectively, CHCS Administrators, Patient

Administration, and Information Assurance officials will produce a monthly report

identifying duplicate records to aggressively find, fix and prevent unnecessary duplicate

patient registrations. (T-1).

4.7.1.3.1. When duplicate patient records are detected in either CHCS or AHLTA,

duplications shall be reported in the Patient Safety Reporting tool. Once the duplicate

record is reported, it will be routed through the Patient Safety Reporting tool to the

TRICARE Operations and Patient Administration flight for resolution by either

merging the records or submitting a MHS Helpdesk Ticket. (T-1).

4.7.1.3.2. There are instances when patients may have multiple eligibilities or are

eligible for care under more than one patient category. Refer to websites in paragraph

4.5.5 for a complete listing of the most common patient categories, the multiple

eligibility that it presents and clear guidance on how to avoid duplicating patients. The

patient category is not static and can be changed; however, it is not automatically

updated when the beneficiary’s status changes in DEERS. The patient category can

and must be changed within CHCS by MTF personnel, when required. (T-1).

Section 4C—Patient Travel

4.8. Patient Accountability for Service Members Traveling to Attend

Medical Appointments and/or Specialty Care.

4.8.1. All service members traveling to any MTF for outpatient medical follow-up or referred

specialty medical care must have the following messages annotated on their travel orders. (T-

1).

4.8.1.1. Section 11 shall indicate, “MTF – TRICARE Operations and Patient

Administration Function and/or AMTU.” (T-1).

4.8.1.2. Section 16 will indicate, “Service members must report to the MTF TRICARE

Operations and Patient Administration Function to have their travel orders validated within

50 AFMAN41-210 10 SEPTEMBER 2019

24-hours of arrival, or the next duty day if arriving on a weekend or holiday. (T-1). All

service members traveling to attend official medical-related appointments or treatment are

required to contact the MTF TRICARE Operations and Patient Administration function

every two weeks to revalidate their orders.” (T-3).

4.9. Patient Travel Benefit.

4.9.1. Travel Reimbursement/Funding. For patients enrolled to a direct care MTF, the travel

benefit is administered by the MTF. For patients enrolled to a network Primary Care Manager,

the TRICARE regional office administers the travel benefit. Exceptions: Travel orders and

funding for AD service members must be the responsibility of the sponsor’s respective Service

branch. (T-1).

4.9.1.1. MTF commander or director will ensure processes are in place for the

accountability of patients entered into the Patient Movement system, see paragraph 4.9.1.2.

This includes using the designated Patient Movement Automated Information Systems

when transport is in excess of 100 miles for ground transportation and for all air

transportation provided under the Defense Travel System. Reference DoDI 6000.11.

4.9.1.2. All staff members utilizing Transportation Command (TRANSCOM) Regulating

and Command & Control Evacuation System (TRAC

ES) will complete a basics user

course and submit a certificate of completion to obtain a TRANSCOM TRAC

ES account.

Training can be requested at transcom.scott.tcsg.mbx.gpmic-global-training@mail.mil.

(T-1). Reference DoDI 6000.11.

4.9.1.2.1. TRANSCOM Regulating and Command & Control Evacuation System

(TRAC

ES) BASICS training can be accomplished three ways:

4.9.1.2.1.1. In residence classroom training at USTRANSCOM Command

Surgeon’s Office; 4.9.1.2.1.2. Online through Joint Knowledge Online (JKO) web

based training; or

4.9.1.2.1.2.1. In-house with a TRAC

ES Trainer that has completed the in-

residence course at the USTRANSCOM Command Surgeon’s Office.

4.9.1.2.2. In-residence class schedules are available by contacting the TRAC

training coordinator via email at transcom.scott.tcsg.mbx.gpmic-global-

training@mail.mil.

4.9.1.2.3. Funding is the responsibility of the member’s unit. Reference DoDI

6000.11.

4.9.2. TRICARE Prime Travel Benefit. When MTF TRICARE Prime enrollees (family

members or military retirees) are referred by their Primary Care Manager for medically

necessary, non-emergency specialty care to a location greater than 100 miles from the referring

primary care manager’s office, the patient must be reimbursed for reasonable travel expenses

in accordance with the Joint Travel Regulations available at available at

https://www.dfas.mil/militarymembers/travelpay/regulations.html. (T-0). Travel

expenses are charged to the MTF.

4.9.2.1. Military Retirees with a Combat-Related Disability Who are Not Enrolled in

TRICARE Prime. When a retired service member with a combat-related disability, who is

not a TRICARE Prime enrollee, is referred by a Primary Care Manager for follow-on

AFMAN41-210 10 SEPTEMBER 2019 51

specialty care, services and supplies, for that particular disability, to a location greater than

100 miles from the primary care provider’s office, the patient must be reimbursed for

reasonable travel expenses in accordance with the Joint Travel Regulation. (T-0). Note:

This also applies to subsequent specialty referrals authorized by a primary care provider.

This benefit is not available overseas.

4.9.2.2. GSU Members. The supporting MTF commander or director has direct control of

patient travel funding for GSU members. When it is unclear who the supporting MTF

commander or director is, the responsibility will default to the nearest Air Force MTF

commander or director to the member’s permanent duty station, unless MAJCOM policy

designates an alternative MTF to provide patient travel support. (T-2).

4.9.3. Non-Medical Attendant Travel. Non-medical attendants are appointed by medical

authority. Local area travel/transportation expense coverage is authorized when serving as a

non-medical attendant for a service member traveling on official business. Non-medical

attendants assisting patients who are referred to medical facilities located beyond the local

permanent duty station area will be reimbursed travel/transportation expenses in accordance

with the Joint Travel Regulation. (T-0).

4.9.3.1. Non-Concurrent Non-Medical Attendant Travel. Non-concurrent non-medical

attendant travel may be authorized or approved when the need for an attendant arises during

treatment or when there is need for an attendant only during a portion of the patient's travel.

4.9.4. Civil Service Family Member of a Seriously Ill or Injured Uniformed Service Member.

A civilian employee, who is authorized travel under a competent travel authorization/order as

a family member of an AD service member who is seriously ill, seriously injured, or when

death is imminent, is treated as an employee in a Temporary Duty (TDY) status.

4.9.5. Travel for Families of Inpatient Service Members who are Very Seriously Ill/Seriously

Ill, or Hostile Not Seriously Injured. Travel for family members of inpatient service members

who are Very Seriously Ill/Seriously Ill or Hostile Not Seriously Injured is governed by the

Emergency Family Member Travel Program (AFI 36-3002, Casualty Services, paragraph

2.25). Emergency Family Member Travel Program is not funded by the MTF. Emergency

Family Member Travel Program is centrally funded by the Air Force, and managed by Air

Force Personnel Center, Casualty Affairs Division (AFPC/DPFC).

4.9.6. Medical Referrals within the Local Permanent Duty Station Area. Travel by personally

owned conveyance to obtain medical care within the local permanent duty station area is

reimbursable only when a service member is ordered (see note below) to a medical facility

within the local area to take a required physical or to obtain a medical diagnosis or treatment.

When ordered, service members are considered to be on official business and must be

reimbursed for the transportation, unless government transportation is available (see Joint

Travel Regulation). (T-0). Note: “Ordered” in this context is defined as an order/command

that could result in disciplinary action if not obeyed (e.g., commander-directed or required by

regulation).

4.9.6.1. Medical Referral Travel at the Member’s Expense. Travel to medical

appointments within the permanent duty station other than as described in the above

paragraph is generally not reimbursable.

52 AFMAN41-210 10 SEPTEMBER 2019

4.9.6.2. Service members traveling on official travel orders outside the permanent duty

station may be authorized travel and transportation allowances in accordance with the Joint

Travel Regulation. Travel must be authorized by the proper medical authority. (T-0).

4.9.7. Medical Referral Travel for Government Employees Overseas and Their Family

Members. When local medical facilities (military or civilian) at a foreign Outside Continental

United States (CONUS) area are not able to accommodate an employee’s dependent’s needs,

transportation to another location may be authorized for appropriate medical or dental care.

Healthcare related travel expenses for an employee or eligible dependent are funded by the

employee’s unit. Travel and transportation expenses and/or reimbursement are authorized in

accordance with the Joint Travel Regulation.

4.9.8. Convalescent Leave Transportation for Illness/Injury. A service member is authorized

transportation allowances (without per diem) for one trip when traveling for convalescent leave

for illness/injury incurred while eligible for hostile fire pay under 37 USC § 310. The

convalescent travel will be funded by the fund cite on the member's deployment travel orders.

(T-1). TDY orders are prepared by the member’s unit. Additional trips, if deemed necessary

by the attending physician, may be authorized through the Secretarial Process. The Secretarial

Process is an action by the Per Diem Travel and Transportation Allowance Committee

(PDTATAC) Principal member or a subordinate level specified by the Principal. The

Secretarial Process is in administrative and procedural issuances issued under the JTR

Introduction (Service or DoD Agency Regulation Review Process).

4.9.9. Travel and Per Diem Allowance. Service members traveling to a medical facility to

obtain an examination or when traveling to Lackland Air Force Base, TX to attend a formal

Physical Evaluation Board, receive travel and per diem (including meals and lodging)

allowance (10 USC § 1210 and Joint Travel Regulation). The service member is authorized

an escort to the place of examination when the member is not physically or mentally able to

travel without assistance.

4.9.9.1. Approximately 20-30 days prior to the reporting date, Air Force Personnel Center,

Disability Division (AFPC/DPFD) will send travel orders to the service member. The

orders will indicate the exact date, time and place to report and includes the authority for

payment of travel costs. (T-1).

4.9.9.2. The destination or examining medical facility will endorse the order with the date

and time the service member reported as verification that the service member was

examined as an inpatient or outpatient. (T-3). The endorsement also serves to verify the

service member was released following the examination.

4.9.9.3. If the service member received an examination as an outpatient, the destination

MTF must indicate whether the service member occupied government quarters during the

stay. (T-3). The examining or destination facility must ensure the service member has an

endorsed order to submit the claim for reimbursement. (T-3). Upon return to the departure

location, the service member is required to submit a travel voucher to their local accounting

and finance office to obtain reimbursement for travel-related expenses. (T-3). Refer to the

Joint Travel Regulation for further travel entitlement information.

AFMAN41-210 10 SEPTEMBER 2019 53

4.10. Transferring Patients Through the Aeromedical Evacuation System. See AFI 48-

307V1, En Route Care and Aeromedical Evacuation Medical Operations, AFPD 10-29,

Worldwide Aeromedical Evacuation Operations.

Section 4D—Quarters Administration

4.11. Quarters Status.

4.11.1. Quarters is a full duty excuse provided to AD uniformed service members receiving

medical or dental treatment for a disease or injury that, based on sound professional judgment,

does not require inpatient care. A quarters patient is treated on an outpatient basis, and is to

remain in their home during the quarters period. Quarters periods generally last 24-72 hours

depending on the providers prescribed rest/recovery period.

4.11.2. The provider or support staff will notify the member’s unit commander or

commander’s designee regarding the patient’s quarters status. The Aerospace Services

Information Management System (ASIMS) Quarters-Airman Medical Notification Module is

the required mechanism for quarters notifications. (T-1). Refer to AFI 41-200, paragraph

3.7.1, 4.3.11.1.1, and 5.1.1.1.2.1 for additional guidance.

4.11.2.1. Disclose only the minimum information necessary.

4.11.2.2. ASIMS automatically accounts for the disclosures at the time it is accessed by

the commander or designee.

4.11.2.3. In the event that ASIMS is not available or the member is from another Service:

4.11.2.3.1. Command authority notification must be documented on DD Form 689,

Individual Sick Slip, or a locally created form. (T-3). See examples located in patient

administration misc. document folder on the AFMOA Health Benefits Kx page at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

4.11.2.3.2. Forward a copy of the quarters notification or DD Form 689 to the

member’s unit commander or designee to receive quarters information. Provide a

second copy of the DD Form 689 to the member to provide to the member’s supervisor.

4.11.2.3.3. If it is necessary to accomplish quarters notification outside of the ASIMS

mechanism, disclosures must be accounted for in the PHI Management Tool or AFMS

approved centralized disclosure accounting tool. (T-2). Reference AFI 41-200.

4.11.3. Develop local procedures for program management, including, but not limited to (T-

3):

4.11.3.1. Notifying Public Health for communicable disease tracking, in the event that

ASIMS is not available or the member is from another Service.

4.11.3.2. Extending quarters past the initial rest period.

4.11.3.2.1. Establishing time limits on 24, 48, & 72-hour quarters. For example, when

an individual is placed on 24-hour quarters, the period expires the next day at the start

of patient’s regular work shift not 24-hours from the time the patient was placed on

quarters.

54 AFMAN41-210 10 SEPTEMBER 2019

4.11.3.2.2. Equally, for 48 hours, the period extends to the start of work on the second

day and for 72 hours, it extends to the start of work on the third day, not to exceed 24,

48, or 72 hours respectively. Unless instructed otherwise, clinic personnel will inform

the patient to report for duty in accordance with the guidelines above.

4.11.4. Unit commanders and supervisors have the authority to grant up to 24 hours sick status

at their discretion if a member’s illness/injury does not require MTF intervention. If the

illness/injury persists beyond 24 hours, then the commander or supervisor must refer the

member to the MTF for treatment and subsequent clinical examination. (T-3).

Section 4E—Line of Duty Program Administration

4.12. Line of Duty Determinations.

4.12.1. Authority: AFI 36-2910. AFI 36-3212, Physical Evaluation for Retention, Retirement,

and Separation.

4.12.2. According to AFI 36-2910, a Line of Duty determination, “Is a finding made after an

investigation into the circumstances of a member’s illness, injury, disease or death.” A service

member who dies or sustains an illness, injury or disease prior to service, while absent without

authority, or due to the member’s own misconduct is not eligible for certain government

benefits.

4.12.3. Following the start of a Line of Duty determination, initial direct care and/or

TRICARE network healthcare may not be denied to any AD service member or RC service

member.

4.12.4. Following the completion of a Line of Duty determination:

4.12.4.1. Direct care and/or TRICARE network healthcare may not be denied to any AD

service member for a Line of Duty determination of Not in Line of Duty is found or

identified.

4.12.4.2. Continued direct care and/or TRICARE network healthcare entitlements of RC

service member may be impacted by Line of Duty determinations.

4.12.5. The Line of Duty determination process is an AF/A1, Manpower, Personnel and

Services, program. The AFMS is not the office of primary responsibility. However, the Line

of Duty determination process is initiated with a medical officer’s review of the member’s

illness, injury, disease, or death. The Line of Duty determination process must be

accomplished in accordance with AFI 36-2910. (T-1). Refer to AFI 36-2910 for information

regarding when to initiate a Line of Duty determination.

4.12.6. The service member’s personnel status and branch of Service usually dictates what

type of Line of Duty form should be used when initiating a Line of Duty determination case.

4.12.6.1. For AD service members and members of the ARC, MTF providers must use the

AF Form 348, Line of Duty Determination or AF Form 348-R, Line of Duty Determination

for Restricted Report of Sexual Assault, for restricted reports. (T-1).

4.12.6.2. For service members assigned to other Service branches (i.e., United States

Army, Navy, Marines), Air Force MTF providers should use the specific Service Line of

AFMAN41-210 10 SEPTEMBER 2019 55

Duty form or the DD Form 261, Report of Investigation Line of Duty and Misconduct

Status when initiating a Line of Duty determination case.

4.12.6.3. An illness, injury, disease or death sustained by member in a duty status is

presumed to be In the Line of Duty. The presumption can be rebutted when evidence

shows the member was not in the Line of Duty. A Line of Duty determination case must

be initiated, whether a member is hospitalized or not, for certain illnesses and injuries. (T-

2). Refer to AFI 36-2910, paragraph 1.6 for definitive information regarding when to

initiate a Line of Duty determination for AD service members and RC service members.

4.12.7. For AD service members, the inability to perform one’s job for 24 hours or more, and

the subsequent placement upon simple quarters for minor injuries and illnesses (including

obstetrical quarters) will likely not require the submission of an AF Form 348 provided:

4.12.7.1. None of the mandatory circumstantial factors or Line of Duty determination/case

initiation triggers identified by AFI 36-2910 are present.

4.12.7.2. The injury or illness is minor and meets the criteria provided under the

Administrative Line of Duty Determination allowances of AFI 36-2910.

4.12.8. If an injured RC service member is taken to a non-MTF for care, the medical officers

assigned to the MTF, Reserve Medical Unit (RMU) or Guard Medical Unit (GMU) who

provided the initial treatment or had first contact with the RC service member should initiate

the Line of Duty determination process.

4.12.9. The medical officer initiating the AF Form 348 will complete blocks 1-11 of the AF

Form 348, sign, stamp or type printed name and title, and date the form. (T-3). The provider

will then contact the appropriate MTF or RC Line of Duty patient administration representative

to initiate the administrative coordination process. (T-3). The Line of Duty patient

administration representative shall ensure that all applicable supporting medical documents

and/or any other medical-related incident or information reports are attached to the AF Form

348 before forwarding the package to the appropriate officials designated in AFI 36-2910. (T-

2). The Line of Duty administrative representative will fill in the “TO, THRU, and FROM”

blocks at the top of the form. (T-3).

4.12.10. In cases where the healthcare provider has determined a Line of Duty determination

review is required for an inpatient admission, the admitting clerk must obtain the time, place

and manner of occurrence of the incident from the patient, other witnesses and/or available

sources and records the information on the reverse of the AF Form 560. (T-3). Again, the

initiating provider completes the appropriate blocks on the AF Form 348, signs the form and

coordinates with the appropriate MTF or RC Line of Duty representative. The Line of Duty

representative will forward the package to the service member’s Military Personnel Section.

(T-1).

4.12.11. The MTF or RC Line of Duty Medical Focal Point representative shall be appointed

in writing by the MTF or RC commander. (T-3). The Line of Duty Medical Focal Point

representative is responsible for (T-3):

4.12.11.1. Educating MTF or RC staff on medical responsibilities for the Line of Duty

process.

4.12.11.2. Processing of all LOD paperwork within the MTF quickly and accurately.

56 AFMAN41-210 10 SEPTEMBER 2019

4.12.11.3. Routing Line of Duties to the appropriate Military Personnel Section special

actions unit or RC personnel processing office in accordance with AFI 36-2910.

4.12.11.4. Ensuring Line of Duties are initiated for local unit attached Individual

Mobilization Augmentee and Participating Individual Ready Reserves reservists.

4.12.11.5. Identifying cases requiring Line of Duty and determinations for AD and RC

service members.

4.12.11.6. Ensuring the appropriate medical officer signs the AF Form 348 before

distributing the AF Form 348 as follows:

4.12.11.6.1. Original: Forward the original and all supporting medical summaries and

supporting documentation to the member’s servicing Military Personnel Section

Special Actions Office.

4.12.11.6.2. Copy: Scan/upload one copy into the member’s approved electronic

health record.

4.12.11.6.3. Copy: File one copy in the Line of Duty - Medical Focal Point Office.

4.12.12. Line of Duty Requirements for Members of the Reserve Component. Reference

DoDI 1241.01, AFI 36-2910 and AFI 36-3212.

4.12.12.1. Government sponsored (Direct Care or TRICARE) healthcare is not authorized

at government expense beyond the period of Inactive Duty Training or drill status orders

for any medical condition that is determined to be not in line of duty. Attempts to complete

Line of Duty determinations should occur prior to the end of the AD orders.

4.12.12.2. The LOD process should be initiated as soon as possible. If the LOD

determination process cannot be initiated by the point of first contact, the process will be

initiated by the RC service member’s servicing MTF, RMU or GMU. (T-1). The LOD

determination process must be accomplished in accordance with AFI 36-2910. (T-1).

4.12.12.3. Any RC service member seeking government sponsored healthcare must

produce at least a partially completed AF Form 348 (1st side completed and signed by the

provider initiating the Line of Duty determination process). (T-1). The partially completed

Line of Duty determination form may be used as healthcare eligibility verification source

when the service member seeks government sponsored healthcare without possessing

current AD status orders or when a DEERS healthcare eligibility check indicates no current

coverage.

4.12.12.4. If a Line of Duty determination cannot be made before the tour of duty ends,

and the individual requires further hospitalization or treatment, continue with any

necessary healthcare related to the potentially service-connected injury or illness.

4.12.12.5. If the final determination is “Not in Line of Duty,” medical care at government

expense ends. Document the notification of the Line of Duty determination in the patient's

medical record(s). If the service member is still hospitalized, advise the patient that as of

the day of notification, care will be provided at the full reimbursement rate until transfer to

a civilian medical facility.

4.12.12.6. If the final Line of Duty determination is “In Line of Duty,” document the

notification and advise the patient that care continues at government expense until service

AFMAN41-210 10 SEPTEMBER 2019 57

member is found fit and returned to duty or separated by the Disability Evaluation System

for the documented medical condition.

4.12.12.7. “Interim” Line of Duty Determination for Healthcare: An informal or formal

Line of Duty investigation, still ongoing, and where a final Line of Duty determination has

not yet been determined. An Interim Line of Duty determination for healthcare is

comprised of the completed medical portion (front part) of the AF Form 348 (with a

provider signature). The form should contain a description of the service member’s illness,

injury or disease, and date of occurrence. In accordance with AFI 36-2910, the military

officer’s signature does not constitute a completed Line of Duty determination. The

Interim Line of Duty determination for healthcare is used to provide eligibility for direct

or TRICARE network healthcare when DEERS indicates a RC service member may not

be eligible for medical or dental benefits. In other words, the completed first side of the

AF Form 348 (including a provider signature) may be used to verify a RC service member’s

entitlement to medical care at government expense when not on AD orders.

4.12.12.8. If the MTF initiates the AF Form 348, the form must be submitted to the

reservist’s Air Force Reserve (AFR) unit or to the RC responsible for uploading the

information into the Electronic Case Tracking. (T-1). The RC will initiate the AF Form

348 through the RC Electronic Case Tracking. (T-1).

4.12.12.9. For Individual Mobilization Augmentee and Participating Individual Ready

Reserves Service Members: The MTF should initiate an AF Form 348 (1st side with

provider signature) and routed in accordance with AFI 36-2910. Notification of ARC

Surgeon General’s Office of initiated Line of Duties for Individual Mobilization

Augmentee and Participating Individual Ready Reserves Service Members is not

necessary.

4.12.12.10. Air National Guard (ANG) Service Members: The medical officers who first

provide treatment or the medical officers stationed nearest to the non-Air Force medical

facility that first provides treatment, in cooperation with the MTF or GMU patient

administration or Line of Duty representative, should initiate the AF Form 348.

4.12.12.11. If the MTF initiates the AF Form 348, the form must be submitted to the ANG

service member’s unit or to the GMU responsible for completing Part I. (T-1).

Section 4F—Air Force Secretarial Designee Program Administration

4.13. Authority. Reference DoDI 6025.23. The use of regulatory authority to establish DoD

healthcare eligibility for individuals without a specific statutory entitlement or eligibility shall be

used very sparingly, and only when it serves a compelling DoD mission interest. (T-0). The

Secretary of Defense and/or the Secretaries of the Army, Navy, and Air Force may designate

individuals not otherwise entitled, for DoD healthcare (medical and dental) in MTFs. The

Secretarial Designee Program only authorizes care within MTFs. Under HQ Air Force Mission

Directive 1-6, Administrative Assistant to the Secretary of The Air Force, the Secretary of the Air

Force has delegated authority to approve medical designee status to the Administrative Assistant

to the Secretary of the Air Force (SAF/AA). Healthcare authorized under this section shall be

provided on a reimbursable basis, unless non-reimbursable care is authorized by this AFMAN or

waived by the Office of the Under Secretary of Defense for Personnel and Readiness or the

58 AFMAN41-210 10 SEPTEMBER 2019

Secretaries of the Military Departments as the approving authorities. (T-0). The level of benefit

and reimbursement rate is determined by the Military Services, using Military Services-specific

criteria.

4.13.1. Reciprocity Among Military Departments and the Defense Health Agency (DHA). Air

Force MTFs will provide treatment to Secretarial Designees from other Military services and

the DHA, subject to the capabilities of the MTF professional staff, availability of space and

facilities, and any other limitations imposed by the approving authority. (T-0). Each

Secretarial Designee agreement must identify the specific MTF in which medical care is

requested, requiring close coordination among service program managers. (T-0).

4.13.2. Each approved Secretary of the Air Force Designee must obtain a signed letter from

the SAF/AA establishing eligibility for care. (T-0). Exception: When a MTF commander or

director authorizes care for newborns of dependent daughters. The letter will include an

effective date, coverage period, aeromedical evacuation/transport determination, the specific

treatment or care authorized in relation to the specific medical condition/incident, and the rate

(charges) for care. (T-2).

4.13.3. Authorization does not entitle a Designee to utilize TRICARE benefits/entitlements.

Approved Designees receive space-available care at the MTF commander’s or director’s

determination, in accordance with Health Affairs Policy 11-005. Unless the authorization

letter specifies otherwise, individual Designees may not use the aeromedical evacuation

system. If aeromedical evacuation becomes a requirement after the SAF/AA has approved the

initial request, a supplemental Designee request must be submitted. (T-2). Designated MTF

personnel may contact AFMOA/SGAT for assistance.

4.13.4. The SAF/AA normally authorizes care for no more than two years. However,

extensions for continuity of care are limited as detailed in paragraph 4.14.4., below. This

program is not intended to provide life-long medical care. Individuals may request renewal of

Designee status and reapply for Designation as outlined in this chapter; however, continued

approval is not guaranteed. Secretarial Designee requests will not be approved for financial or

humanitarian purposes. (T-1). It will not be the process in which to offer an individual debt

relief.

4.13.5. Individuals being considered for Secretarial Designee status (not currently eligible for

care) shall not receive treatment at Air Force MTFs until Secretarial Designee status has been

approved. (T-2). An exception to this requirement is Extracorporeal Membrane Oxygenation,

or partial heart-lung bypass. In this situation, the MTF is required to initiate a verbal request

via telephone communication through the Air Force Surgeon General’s Medical Operations

Center. (T-2).

4.13.6. MTF Secretarial Designee Program Managers should educate MTF professionals,

medical support (outpatient and inpatient) and ancillary staff members of the purpose of the

Secretarial Designee Program and its basic requirements. Clinical professionals and

immediate medical support staff are best positioned to identify patients who may benefit from

potential Secretarial Designee status.

4.13.6.1. If Secretarial Designee status is identified as a potential option, clinicians and

medical support staff should proactively submit a timely application. The staff may

identify a potential designee through the normal course of treatment for a MHS beneficiary

AFMAN41-210 10 SEPTEMBER 2019 59

for whom healthcare benefits are soon to expire; in such case, staff should determine

eligibility loss date and begin the application process. Staff may also identify a potential

designee when that person is treated as an emergency patient.

4.13.6.2. MTF requests must be received by AFMOA/SGAT no later than 30 days prior

to expiration of medical benefits. (T-2). Individuals who have lost their military medical

benefits and are being considered for Secretarial Designee status will no longer receive

treatment at Air Force MTFs until Designee status has been approved.

4.13.6.3. Situations where patient healthcare eligibility has expired and Secretarial

Designee approval has not been granted could potentially leave the patient without

healthcare coverage; further, these situations could force the applicant to incur a financial

burden, especially if the designee request is disapproved.

4.13.6.4. Application denials for healthcare already provided will automatically generate

charges at the full reimbursement rate. Retroactive requests should be limited to absolutely

unavoidable situations such as short-notice separations. The MTF must notify

AFMOA/SGAT immediately of urgent cases. (T-2).

4.13.7. Each application shall include a DEERS and identification check to verify the status

of the patient and sponsor. (T-2). The MTF law consultant or base Legal Office will review

applications and include the review as part of the Secretarial Designee request. (T-3).

4.13.8. Typically, in emergency (life, limb, eyesight, or relief of undue suffering) cases that

present at a MTF, healthcare personnel can provide necessary treatment to stabilize the

individual without the need to pursue a Secretarial Designation. However, for longer-term

care, there could be a need to pursue approval to treat via this Secretarial Designee process

identified in this AFMAN.

4.14. U.S. Air Force Secretarial Designee Criteria. Individuals who meet one or more of the

following criteria may apply for Secretarial Designee status through the requesting MTF using the

sample format in Attachment 2. When submitting applications, choose the most appropriate

category for the request.

4.14.1. Teaching Case. When the case presents a unique teaching opportunity for the MTF

staff or residency programs, an individual may request Designee status. If this option is

selected, the MTF attending physician or primary physician advocate must include a thorough,

written, signed statement that identifies the specific benefits to the Air Force. (T-2). The

application must then be endorsed by the attending physician’s department chairperson, the

Director of Graduate Medical Education, and the Chief of the Medical Staff. Each signature

is required to validate the teaching significance of the case. For example, the case is critical

for continued accreditation of a training program; is an extremely rare case; the case is a

necessary part of a training program protocol and the patient case mix is not available in the

beneficiary population. MTF healthcare will, under most circumstances, be provided at the

family member rate. Use this paragraph for teaching cases that fall outside paragraph 4.14.2.2

for Extracorporeal Membrane Oxygenation Program cases.

4.14.2. SAF/AA Delegated Approval Authority Programs.

4.14.2.1. Civilian Trauma Program. In certain instances and at certain locations, SAF/AA

designates authority to the MTF commander or director to identify civilian trauma patients

60 AFMAN41-210 10 SEPTEMBER 2019

as Secretarial Designees under the parameters SAF/AA determines appropriate. Upon

expiration of eligibility initially established through this delegated authority, additional or

continued care requires a full Secretarial Designee application and approval by the

SAF/AA. (T-2). If the additional or continued care is approved, the Designee will pay the

Full Reimbursement Rate for healthcare provided under the Secretarial Designee program.

4.14.2.2. Extracorporeal Membrane Oxygenation Program (partial heart-lung bypass). If

a patient requires Extracorporeal Membrane Oxygenation or partial heart-lung by-pass, the

MTF will initiate the application with a verbal request through the Air Force Surgeon

General’s Medical Operations Center to the SAF/AA. (T-2). All verbal requests to grant

Secretarial Designee status for Extracorporeal Membrane Oxygenation treatment must

include: patient demographics, citizenship of patient, pick up location, type of military

transport (air/ground), diagnosis, justification for the mission, requested length of

Secretarial Designee status, if follow-on inpatient care at a MTF is required and if patient

has health insurance. (T-2). Transportation on civilian air or ground ambulances or

treatment at a civilian medical facility is not authorized under the Secretarial Designee

Program. To gain approval of all requests the Medical Operations Center will notify the

appropriate point of contacts. The Medical Operations Center will coordinate with the

AF/SG and the Air Force Deputy Surgeon General (AF/DSG) prior to engagement with

SAF/AA. The Medical Operations Center will simultaneously notify Secretary of the Air

Force International Affairs (SAF/IA) if the request involves a non-United States citizen or

a foreign country. The MTF will submit the full and complete electronic application within

24 hours to AFMOA/SGAT. AFMOA will email the formal package directly to SAF/AA

with a courtesy copy to the Medical Operations Center. (T-2).

4.14.2.3. Human Immunodeficiency Virus (HIV) Research Program.

4.14.3. Best Interest of the Air Force. This category of Designees includes those for whom it

is in the best interest of the Air Force to provide continued care. For cases when the

justification is in the best interest of the government, include a letter from the MTF, addressing

the effects of denying Designee status (e.g., litigation risk, cost, negative press coverage). Care

will under most circumstances be provided at the family member rate. (T-0).

4.14.4. Continuity of Care. If continuity of care is a significant clinical issue in the individual's

course of treatment and civilian medical care is not available or appropriate, this individual

may request Designee status. Care is limited to a period of six months, or in the case of

pregnancy, until the completion of the pregnancy. For cases when the justification is continuity

of care, the case must be medically supportable. (T-0). Include a statement on the medical

impact if the Air Force were to deny the individual Designee status.

4.14.4.1. Obstetrics, Maternal, and Pediatric Care Sub-Category: The MTF commander

or director or designated representative may approve Designee status for applicants

identified below at the family member rate unless the Designee has other health insurance.

4.14.4.1.1. Newborns of eligible family member daughters.

4.14.4.1.2. Pregnant former AD members and their newborns.

4.14.4.1.3. Spouses of former AD and their newborns.

AFMAN41-210 10 SEPTEMBER 2019 61

4.14.4.1.4. Family member dependent daughters who became pregnant prior to losing

eligibility and their newborns.

4.14.4.1.5. Newborns of widows losing transitional survivor benefits.

4.14.4.2. In the case the Designee has other health insurance, the rate will be the Full

Reimbursement Rate. MTF healthcare is generally limited to pre-partum obstetrical care,

MTF newborn delivery, one post-partum check-up (for the mother), well baby outpatient

visits for the infant and any necessary immunizations for the infant, all to be provided no

later than six weeks following delivery.

4.14.5. Abused Family Members and Dependents. This section is only applicable if all or

some transitional benefits are denied by the Air Force Personnel or Finance Authorities, and/or

the Defense Finance and Accounting Service. If all or some transitional benefits, discussed in

AFI 36-3024, Transitional Compensation for Abused Dependents, are denied, a discharged or

separated service member’s family member/dependents may apply for consideration of limited

(MTF direct care only) medical benefits under the Secretarial Designee program. Approval is

not guaranteed. If approved, healthcare is specifically limited to medical services necessary to

treat injuries or illnesses suffered as a direct result of the sponsor’s abuse.

4.14.5.1. Notification or receipt of denial of transitional compensation benefits (from the

installation Military Personnel Section or Finance Office) does not necessitate MTF

obligation to automatically submit a Secretarial Designee application on behalf of the

abused family member(s). The MTF is only required to submit an Air Force Secretarial

Designee application to the SAF/AA (via AFMOA/SGAT intermediary), if requested in

writing by one or more family members of the discharged service member. (T-2).

4.14.5.2. Confirmation of this action must be coordinated with the abused family member

dependent(s) or legally authorized representative(s). (T-0). The MTF location responsible

for assembling the Secretarial Designee package should include the standard application

package documentation identified at Attachment 2 and, to include the application letter and

medical summary or statement that clearly identifies the medical illness, injury or condition

(related to, or as a consequence of abuse) for which military healthcare is requested. See

example at Attachment 2.

4.14.6. Foreign Military Sales Case. If the country has an open Foreign Military Sales case,

the Air Force may bill the costs for the additional study to that case number. In other situations,

the requesting country may have the Air Force bill sent to another United States controlled

fund or may have the bill sent to their Embassy. The applicant must provide billing information

before the Air Force decides on the availability of the requested service.

4.14.7. Special Foreign Nationals. The Secretary of the Air Force may authorize Air Force

healthcare benefits to foreign nationals considered to be critically important to the interests of

the United States The Secretary of the Air Force may use this authority for individual

designations, on a case-by-case basis. Such a designation does not create a new category of

beneficiaries.

4.14.7.1. Criteria for selection as a Secretary of the Air Force Designee for foreign

nationals:

62 AFMAN41-210 10 SEPTEMBER 2019

4.14.7.1.1. Foreign nationals nominated for Designee status must be Heads of State,

Cabinet members (Minister), Chiefs of Staff of the Armed Forces, or hold equivalent

positions. (T-0).

4.14.7.1.2. Appropriate healthcare must not be available in the nominee's country or

in a civilian healthcare facility in the United States. (T-0).

4.14.7.1.3. The nominee or his government must agree to assume responsibility for

payment of DoD healthcare services (at the Full Reimbursement Rate) if the individual

requested and the Air Force approved the cost of aeromedical evacuation. (T-0).

4.14.7.2. Designation procedures:

4.14.7.2.1. Foreign governments seeking Designee status will submit requests to the

State Department through the mission chief of the country involved. The request must

contain the full name and title of the individual, an explanation of why the individual

is critical to United States’ interests, the pertinent medical information, the billing

address, individual or office, and a certification that the nominee meets the necessary

criteria. (T-0).

4.14.7.2.2. Refer inquiries from foreign embassies in Washington, or other sources to

the United States Chief of Mission in the country concerned.

4.14.7.2.3. The State Department reviews the request and refers it to the appropriate

agency Secretary with a recommendation for approval.

4.14.7.2.4. The Request is submitted to the Secretary of the Air Force for review. If

approved, the Secretary's office forwards it to the Office of the AF/SG for appropriate

action. AFMOA/SGAT prepares the request and assigns responsibility for moving the

Designee through the Patient Movement Requirements Center to the specific overseas

or CONUS MTF.

4.15. Applying for Air Force Designee Status. When evaluating a Designee application, MTF

commanders or directors should consider the availability of MTF capabilities and resources. If

adequate capabilities exist, and the applicant does not meet or qualify for any initial or continued

sponsor service affiliation for DEERS enrollment, eligibility, and/or medical entitlement identified

in AFI 36-3026_IPV1, then the MTF commander or director should review and sign the

application package recommending whether or not Designee status is warranted. The package is

then forwarded to AFMOA/SGAT for processing. The MTF shall electronically submit (via e-

mail encryption) a Secretarial Designee application to AFMOA/SGAT no later than 30 days prior

to expiration of medical benefits or requested Designee start date. (T-2). The 30 day window

allows enough coordination time to submit the Secretarial Designee application to the SAF/AA

for review and approval consideration. See example of Designee application at Attachment 2.

4.15.1. Forward all United States Air Force Secretarial Designee requests electronically to

AFMOA/SGAT. Because designee applications may contain PHI or sensitive medical

information, e-mail messages must only be forwarded to higher HQ using government

Common Access Card digital signature and encryption protocols. (T-0). If unable to send an

encrypted message, the package may be sent using Encryption Wizard/AMRDEC SAFE

requirements in accordance with AFI 41-200, paragraph 7.8, or mailed using a commercial

AFMAN41-210 10 SEPTEMBER 2019 63

overnight express mail shipping company or First Class United States Postal Service overnight

or express mail with return receipt or other package tracking option.

4.15.2. Each request is required to be coordinated with an AFMOA/SGAT representative. (T-

2). AFMOA/SGAT will review and coordinate the request package for a legal review prior to

submitting to the SAF/AA. AFMOA will submit all “retroactive” requests to the AF/SG for

coordination and approval consideration prior to further submission to the SAF/AA. All

request packages must contain the AFMOA electronic Staff Summary Sheet, the MTF

application, and a legal review. (T-0).

4.15.3. If the request pertains to a sponsor or member who is due to separate and/or be

discharged from the Air Force, the request package must include a copy of the sponsor’s or

member’s separation orders and DD Form 214, Certificate of Release or Discharge from Active

Duty, and the line of duty determination for RC service members, when applicable (T-3).

4.15.4. AFMOA/SGAT officials, with concurrence of respective MAJCOM command

surgeons, are authorized to reject applications that do not meet the requirements identified in

this chapter. Applications that are denied or rejected by AFMOA officials and the MAJCOM

command surgeon do not need to be routed through or submitted to the SAF/AA. Ensure

request packages are accurate, current and contain all necessary supporting documentation.

4.15.5. AFMOA will forward United States Air Force Secretarial Designee requests via e-

mail to the SAF/AA.

4.15.6. The electronic Staff Summary Sheet must contain (at a minimum) purpose,

background, discussion, options and recommendation. (T-1). The discussion must include a

justification that specifies which of the criteria in paragraph 4.14 the request is based upon,

and an explanation of how the request relates to those criteria. (T-1). The discussion must also

include the eligibility duration being requested. (T-1).

4.15.7. The Secretarial Designee approval letter must contain the designee’s name, eligibility

duration, designation criteria being met, aeromedical evacuation determination,

reimbursement rate, statement limiting care to MTF authorized care only for the specified

illness or injury and any applicable third party insurance. (T-1).

4.15.8. The determinations of all designee cases and respective application packages

submitted to and returned from the SAF/AA will be returned to AFMOA/SGAT who will then

notify the applicable MTF and/or MAJCOM so the individual can be notified. MTF will file

a copy of the letter in the individual’s outpatient medical record. (T-3).

4.15.9. Reporting. The annual Secretarial Designee Log will be forwarded annually (FY) to

AFMOA/SGAT no later than 15 October. (T-1). Following report collection and quality

review, officials at AFMOA/SGAT will then forward the reports to the SAF/AA no later than

30 October.

4.15.9.1. Overseas MAJCOM commander surgeons, MTF commanders and directors will

report data on the individuals approved under SAF/AA delegated authority (locally

approved). (T-3).

4.15.9.2. All reporting data is PHI and will be transmitted in accordance with appropriate

safeguards. (T-0).

64 AFMAN41-210 10 SEPTEMBER 2019

4.16. Certain Senior Officials of the United States Government. Certain senior officials

within the Government, including the DoD and the Military Departments, have Secretary of

Defense Designee status for medical care and dental care in military medical or dental treatment

facilities.

4.16.1. The Secretary of the Air Force recognizes Secretary of Defense Designees in

accordance with DoDI 6025.23, Enclosure 2. Family members are not included unless

otherwise stated. See DoD 6025.23 for instructions on Health Care Eligibility Under the

Secretarial Designee (SECDES) Program.

4.16.2. Applicable charges for Secretary of the Air Force Designees. The Secretary of the Air

Force has authorized the individuals listed in DoDI 6025.23 Enclosure 2 to receive space-

available inpatient and outpatient health care services from United States Air Force MTFs on

a reimbursable basis.

4.16.3. See AFI 48-307V1 for instructions on Aeromedical Evacuation operations.

4.17. Operating the Air Force Secretarial Designee Program Overseas. In accordance with

HAF Mission Directive 1-6, Administrative Assistant to the Secretary of the Air Force, HAF

Mission Directive 1-48, The Air Force Surgeon General, and DoDI 6065.23 Health Care

Eligibility Under the Secretarial Designee (SECDES) Program and Related Special Authorities,

the Command surgeons at HQ United States Air Force Europe Air Forces Africa (HQ USAFE-

AFAFRICA) and HQ Pacific Air Forces (HQ PACAF) for their respective theater have the

authority to designate individuals for care in overseas MTFs. This authority does not extend to

authorizing transportation to the CONUS.

4.17.1. United States Citizens. The Air Force tries to keep the number of United States

citizens who commanders can designate to an absolute minimum. Most United States citizens

who fall under this paragraph are returning hostages and individuals involved in prisoner

exchanges. There may be other occasions when designating United States citizens would be

appropriate.

4.17.2. Foreign Nationals. Commanders who use the authority under this paragraph must

issue guidelines on medical care for nationals of foreign nations. (T-2). These guidelines must

identify the categories of persons, both military and civilian, who have authorization for

medical care within the provisions of this paragraph. (T-0). Individuals, whom the commander

designated under this paragraph, must contribute to the advancement of United States public

interests. (T-0). Generally, only officials of high national prominence are made Designees.

Sometimes, a commander grants designee status when there are special, unusual or

extraordinary circumstances. The Air Force may not provide care for foreign nationals with

incurable diseases or who require excessive nursing care. Commanders should seek

recommendations from the chief of the diplomatic mission or embassy to the country involved

before authorizing care to any foreign national. The Air Force collects charges for the

Designee’s care locally.

4.18. Designee Status Used in Claims Against the United States. Designee status is not used

in the claims process.

AFMAN41-210 10 SEPTEMBER 2019 65

Section 4G—Exceptional Family Member Program

4.19. Exceptional Family Member Program (EFMP). MTFs will standardize the location of

Exceptional Family Member Program enrollment and relocation clearance functions within

Medical Management offices. (T-1). Refer to AFI 40-701, for additional information.

4.20. Family Member Relocation Clearance Coordinator (FMRCC). The individual

responsible for ensuring administrative process requirements are met is the Family Member

Relocation Clearance Coordinator. Refer to AFI 40-701, for additional information.

Section 4H—Admissions and Dispositions Program Administration

4.21. Responsibility for Admission Processing. Unless otherwise specified, Patient

Administration is responsible for administrative needs required for the admission and disposition

of patients.

4.22. Administrative Admission and Disposition Requirements. The Admissions and

Dispositions Office will verify authorized eligibility for healthcare for 100% of inpatient

admissions.

4.22.1. For all admissions, enter the patient’s demographic and personal data via the FULL

patient registration menu.

4.22.2. Notify the military patient’s commander, first sergeant or other appropriately

appointed commander’s designee, of member’s admission. All disclosures of PHI to

commanders will be tracked in accordance with AFI 41-200. (T-0)

4.22.3. Determine at the time of admission if the patient will opt in or opt out of the Facility

Directory and make appropriate documentation. See AFI 41-200, paragraph 4.2.1, for

additional information.

4.22.4. If communication with the member’s commander, first sergeant, or other appropriately

appointed commander’s designee is not possible, then contact the service member’s

installation command post or installation operations/control center. Release only Sanitized

Healthcare Information to the member’s installation command post or control center staff.

4.23. Assuming Administrative Responsibility for Military Members Hospitalized in Non-

Military Medical Facilities also known as Absent Sick Status.

4.23.1. The MTF commander or director at the nearest Air Force MTF shall assume the

primary administrative support responsibility (including appropriate service member

identification, monitoring, “tracking,” clinical secondary support, advice, analysis, and/or

consultation) for any AD service member referred to, hospitalized, or admitted to a non-

military medical facility. (T-1). AD service members admitted to non-military civilian medical

facilities are referred to as being in an “Absent Sick” or ABS status (menu path in CHCS).

4.23.2. If necessary, the nearest Air Force MTF shall serve as an information conduit between

the civilian or non-military medical facility, the service member’s family, and the service

member’s chain of command. (T-1).

4.23.3. Each MTF TRICARE Operations and Patient Administration function or Admissions

and Dispositions Office is responsible for identifying and tracking each known Air Force AD

66 AFMAN41-210 10 SEPTEMBER 2019

service member hospitalized or admitted to a civilian or non-military medical facility.

Established or perceived geographic boundaries, TRICARE Prime Service Areas, or other

distance or mileage restrictions or arguments, shall not relieve a MTF from its obligation to

identify, monitor, track, or support a hospitalized Airman unless another Air Force MTF, has,

or will assume primary administrative support responsibility. (T-1). Support obligations may

extend hundreds of miles if no other Air Force MTF exists in a particular region or if no other

Air Force MTF has been identified as having primary administrative support responsibility.

4.23.4. Notwithstanding the provisions identified immediately above this paragraph, the

nearest MTF will assume primary administrative support responsibility for all known Air Force

AD service members, regardless of type of injury or illness, whether hospitalization was

planned, scheduled, resulted from emergent, urgent, non-emergency, non-urgent, battle or non-

battle related circumstances.

4.23.5. All known Air Force Wounded Warriors will be identified, tracked, and supported by

the nearest Air Force MTF. (T-3).

4.23.6. Any seriously ill or injured Air Force AD service members will be identified, tracked,

and supported by the nearest Air Force MTF. (T-3).

4.23.7. All Air Force AD service members referred from the MTF, to a civilian or non-military

medical facility will be monitored and tracked. (T-3).

4.23.8. Minimum Processes Required to Identify, Monitor, and Track Absent Sick Patients.

4.23.8.1. Tracking Requirements for Inpatient or Bedded MTFs:

4.23.8.1.1. At a minimum, the Admissions and Dispositions Office will use the CHCS

automated computer system to support their identification, monitoring, and tracking,

efforts of each known Absent Sick patient. (T-3).

4.23.8.1.2. Record the admission in the CHCS Patient Administration module using

the Admissions, Discharges, and Transfer secondary menu and Admissions sub-menu.

4.23.8.1.3. If a decision to transfer the service member-patient from the civilian or

non-military medical facility to the MTF is authorized, then the MTF Chief of the

Medical Staff is responsible for identifying the admitting MTF physician. The

Admissions and Dispositions Office leaves the admission category type as ABI (menu

path in CHCS) and enters the transfer date and time into CHCS. Maintain the same

4.23.8.1.4. If the service member-patient remains in the civilian or non-military

facility for the duration of inpatient treatment, the MTF Admissions and Dispositions

Office will change the admission category type from ABI to ABS (Absent Sick). After

confirming the service member-patient has been discharged from the civilian or non-

military medical facility, then discharge the service member-patient in CHCS.

4.23.8.1.5. Request a complete summary of the patient’s treatment from the civilian or

non-military medical facility before the patient is transferred to the MTF or after the

patient has been discharged from the civilian medical facility.

4.23.8.2. Tracking Requirements for Outpatient or Non-Bedded MTFs: Place any medical

documents received from the civilian or non-military medical facility into a secure, locked

AFMAN41-210 10 SEPTEMBER 2019 67

transitory file within the office responsible for providing or facilitating the majority of the

administrative support responsibility. Upon discharge from the civilian medical facility,

the office responsible for administrative support will scan/upload the documents into the

patient’s electronic health record.

4.23.9. The nearest MTF should recommend to the hospitalized AD service member that an

information release authorization should be signed to allow the civilian or non-military medical

facility to disclose treatment information to the supporting MTF.

4.23.10. Obtain full patient identification from the civilian or non-military medical facility and

promptly notify the patient’s unit commander by telephone with the patient’s name and

location.

4.23.11. When possible, obtain comprehensive medical information regarding the AD service

member’s condition. The civilian or non-military medical facility is financially reimbursed

for the patient’s care based on the Diagnosis Related Group, known as a patient classification

system that standardizes prospective payment to hospitals. A complete summary of the

patient’s treatment while under the care of the civilian healthcare provider is required after the

patient has been discharged.

4.23.12. When no MTF has assumed administrative support responsibility, Air Force points

of contact at DHA-Great Lakes should contact the MTF located nearest to the AD service

member’s location if DHA-Great Lakes received information from:

4.23.12.1. The admitting civilian or non-military medical facility

4.23.12.2. The TRICARE managed care support contractor or regional office

4.23.12.3. An AD service member’s family member.

4.23.12.4. Other sources of information.

4.23.13. When hospitalized at a uniformed services treatment facility or VA hospital, the

nearest MTF assumes administrative support responsibility. The responsible MTF will arrange

for a transfer to a MTF when it is safe to transport the service member. (T-2).

4.23.14. If the service member is referred to a Uniformed Services Treatment Facility or VA

hospital, the referral MTF maintains administrative support responsibility.

4.23.15. Unit commanders must notify the nearest Air Force MTF and the DHA-Great Lakes

(1-888-647-6676) as soon as possible if one of the commander’s unit members in the following

categories is hospitalized in a civilian or non-military medical facility:

4.23.15.1. ARC service members (related to an In-Line-of-Duty occurrence or incident),

4.23.15.2. AD service members assigned to GSU,

4.23.15.3. TRICARE Prime Remote AD Service Member.

4.23.16. Admissions and Dispositions Office will notify the base occupational safety office

and resource management office in accident cases using AF Form 1488, Daily Log of Patients

Treated for Injuries. (T-1). Account for disclosure in accordance with AFI 41-200, paragraph

3.7.

68 AFMAN41-210 10 SEPTEMBER 2019

4.24. Assuming Administrative Responsibility for AD U. S. Air Force Members Hospitalized

in DoD Facilities.

4.24.1. The nearest Air Force MTF commander or director assumes administrative

responsibility and Patient Administration staff ensures that the following procedures are

carried out for Air Force personnel hospitalized in Army or Navy MTFs:

4.24.1.1. Facilitates necessary communication between members’ unit commander, and

officials at the Army or Navy MTF. All disclosures of PHI to commanders will be tracked

in accordance with AFI 41-200. (T-0).

4.24.1.2. Keeps rosters and pertinent data on hospitalized Air Force patients and notifies

the members’ unit commander immediately upon notification.

4.24.1.3. Prepares AF Form 348, when applicable, in accordance with AFI 36-2910.

4.24.1.4. Notifies the base occupational safety officer in accident cases.

4.24.2. Within the CONUS, patients may be administratively assigned or attached to the

closest Air Force MTF Airman Medical Transition Unit nearest to the Army or Navy MTF

providing medical care. See paragraph 4.68 for Airman Medical Transition Unit assignments.

4.24.2.1. Prepares AF Form 1488 when applicable and forwards it to the base occupational

safety office and Resource Management Flight.

4.24.2.2. Serves as the admitted member’s local representative for all patient

administration related matters.

4.24.3. See Section 4I, Casualty Reporting Program Administration, for Seriously Ill and/or

death cases.

4.25. Admitting Infants Born Outside the MTF.

4.25.1. Infants born outside the MTF (e.g., at home or enroute to the hospital) are admitted to

the MTF as “Liveborn” or “Newborn” when the mother is also admitted for post-partum care

within 24 hours following delivery. If the infant is admitted outside the 24 hour window or if

the mother is not admitted at the same time as the infant, then the infant is admitted as a direct

admission.

4.25.2. If the infant’s birth and subsequent admission first occurred in a civilian hospital and

the mother and baby are later transferred to a MTF, admit the infant in CHCS using the CIV-

INITIAL ADM TO NON-U.S. MILITARY HOSP, MOVED TO MIL MTF (NON AD)

admission/transfer code (Source of Admission Code 5) instead of a Direct, Newborn, or

Liveborn admission.

4.25.3. When a newborn infant is transferred from one MTF to another MTF, the receiving

MTF generally admits the infant using the TAF-TRANSFER FROM AF HOSPITAL; TAR-

TRANSFER FROM ARMY HOSPITAL; or TNF-TRANSFER FROM NAVY HOSPITAL

admission/transfer code instead of a Direct, Newborn, or Liveborn admission.

4.26. Admitting Generals/Admirals (Flag Officers), Colonels, and Prominent Persons. All

disclosures of PHI to Commanders will be tracked in accordance with AFI 41-200. (T-0).

4.26.1. Terms:

AFMAN41-210 10 SEPTEMBER 2019 69

4.26.1.1. General/Admiral Officer (GO): Includes all AD, RC (of any Uniformed Service

branch) and foreign general flag officers (0-7 and above).

4.26.1.2. Colonel: Applies only to AD Air Force colonels that are Seriously Ill /Very

Seriously Ill, expected to be hospitalized for a non-scheduled emergency hospital stay

greater than 10 days, or any Air Force colonel provided a profile change for any serious

medical or surgical condition affecting the member’s assignment availability or command

obligation. This reporting rule also includes any AFMS colonel (Medical Corps (MC),

Dental Corps (DC), Nurse Corps (NC), Medical Service Corps (MSC), and Biomedical

Sciences Corps (BSC)) who has been admitted as an inpatient under emergent

circumstances.

4.26.1.3. Prominent Persons:

4.26.1.3.1. Senior Executive Service (SES) federal civilian officials, political officials

or officers, high-ranking public officials, federal judges who are expected to be

hospitalized for a non-scheduled, emergency hospital stay greater than 10 days.

Notifications for persons in this category require the patient’s authorization.

4.26.1.3.2. Current Chief Master Sergeant of the Air Force and any AD AFMS Chief

Master Sergeant.

4.26.1.4. Admission and Extended Ambulatory Care: Admission to a MTF, non-federal

hospital, or any facility for which the nearest MTF assumes administrative responsibility.

This includes inpatient units and other extended care services (e.g., ambulatory patient

visits, observation and partial hospitalization).

4.26.1.5. Information Conduits: Command Posts, Operations Centers at the installation or

MAJCOM level. AF/SGXO, Air Force Medical Operations Center can be reached at

Defense Switched Network (DSN) 227-9075 or commercial (703) 697-9075.

4.26.2. Local and MAJCOM Notification Procedures when a General/Flag Officer, Colonel,

or Prominent Person (fitting the description listed in the above paragraphs), is Admitted.

4.26.2.1. The Admissions and Dispositions Office (or similar Patient Administration

location or office) will contact the MTF commander or director and provide sanitized

information regarding the admission. (T-1).

4.26.2.2. The Admissions and Dispositions Office (or similar Patient Administration

location or office) will contact the local base or wing command post and the command post

or operations center of the admitted military official. Provide only sanitized information.

(T-2).

4.26.2.3. The Admissions and Dispositions Office (or similar Patient Administration

location or office) will contact their MAJCOM command surgeon or AFMOA Health

Benefits Regional Branch. (T-2).

4.26.2.4. The MTF commander or director will notify the installation commander (via

appropriate information conduits) and release only minimum necessary information. (T-

2).

4.26.2.5. Notifications will be made as soon as possible, no later than 12 hours after

admission or initial treatment. (T-2).

70 AFMAN41-210 10 SEPTEMBER 2019

4.26.3. HQ USAF Notification Procedure when a General/Flag Officer, Colonel or Prominent

Person is admitted or remains in the MTF.

4.26.3.1. Inpatient/bedded MTFs will contact the Pentagon AF/SG Military Operations

Center by 0600 Eastern Time every duty day to include negative replies. (T-1).

4.26.3.2. Provide only sanitized information to the Medical Operations Center. Include

telephone call back phone numbers so Medical Operations Center officials can obtain

comprehensive medical information as needed.

4.26.3.2.1. In unusual circumstances, if the MTF commander or director determines

the AF/SG should be notified during non-duty hours, call the Air Force Service Watch

Cell, DSN 227-6103, commercial (703) 697-6103.

4.26.4. HQ USAF/Medical Operations Center Responsibilities:

4.26.4.1. Medical Operations Center officials will create two word-processing (letter)

documents from the information. (T-1).

4.26.4.1.1. The first document includes sanitized information only.

4.26.4.1.1.1. The sanitized information document is transmitted, in password

protected or encrypted mode only, to the Chief, United States Air Force General

Officer Matters Office (AFGOMO) via the Pentagon e-mail address.

4.26.4.1.1.2. AF/SG, AF/DSG or a representative will receive the information via

live brief or in password protected or encrypted electronic format. AF/SG,

AF/DSG or a representative will provide the information to Chief of Staff, United

States Air Force (CSAF). (T-1).

4.26.4.1.1.3. If the document contains information regarding any colonel that has

been admitted or treated and meets the criteria indicated in paragraph 4.25.1.2., the

password protected or encrypted electronic transmission will be provided to the

United States Air Force Colonel Matters Office Support Division. (T-1).

4.26.4.1.2. The second document will include comprehensive medical information and

be provided only to AF/SG, AF/DSG or a representative. (T-1).

4.27. Reporting Aircraft Accident Admissions.

4.27.1. For specific instructions, see AFI 91-204, Safety Investigation and Hazard Reporting.

The Medical Group, Chief Aerospace Medicine (MDG/SGP) makes initial notification to the

command surgeon of the MAJCOM. The command surgeon of the MAJCOM that the aircraft

is assigned notifies Air Force Medical Support Agency (AFMSA)/SG3P, DSN 761-7242 or

DSN 761-7616, commercial 703-681-7616) of any admission resulting from an aircraft

accident (regular Air Force, AFR, or ANG).

4.27.2. Provide the diagnosis, estimated period of hospitalization, and probable disposition of

personnel.

4.27.3. During regular duty hours, notify AFMSA/SG3P (Aerospace Medicine) by telephone.

After duty hours, notify AF/SG Duty Officer through the AFMOA, DSN 227-9075 or

commercial (703) 697-9075. The MAJCOM command surgeon is required to provide the date

of the victim’s initial clinic visit, diagnosis, estimated period of treatment, and the probable

AFMAN41-210 10 SEPTEMBER 2019 71

disposition of all personnel who are examined or received treatment for injuries incurred as a

result of an aircraft accident.

4.28. Managing Military Patients Expected To Be Hospitalized Over 90 Days.

4.28.1. MTF staff must notify the patient’s servicing MTF and Military Personnel Section

when a patient will be reassigned or hospitalized over 90 days. (T-2).

4.28.2. For patients hospitalized while traveling to a CONUS port for permanent change of

station overseas, the staff at the admitting MTF must advise the local Traffic Management

Office and Military Personnel Section of the patient’s hospitalization and the expected

duration. (T-2).

4.28.3. The patient may be assigned or attached to the Airman Medical Transition Unit. See

paragraph 4.67 in this AFMAN.

4.28.4. Under this section, all disclosures of PHI to commanders will be tracked in accordance

with AFI 41-200. (T-0).

4.29. Deployed Military Members who are Aeromedically Evacuated from Contingency

Operations to CONUS MTF.

4.29.1. Deployed Air Force service members (who are on Contingency, Exercise, Deployment

(CED) orders) and are aeromedically evacuated to a CONUS MTF from a Contingency Area

of Responsibility (for example, from Landstuhl Regional Army Medical Center to National

Naval Medical Center) will remain on CED orders until returned to their home station

(permanent duty station). (T-1). Medical TDY orders will not be prepared. (T-1). The

member’s per diem is covered by their CED orders.

4.29.2. CED orders will be extended, if necessary, until the member returns to their home

station. (T-2).

4.29.3. Ambulance Transport for members on CED orders is funded by Defense Health

Program Overseas Contingency Operations (OCO) Supplemental Funds.

4.29.4. Travel per diem expenses of Air Force members transported from a MTF to a

Comprehensive Care Facility are covered by member’s (CED) orders.

4.29.5. Travel and per diem expenses of Air Force members transported from a MTF to home

station is covered by member’s CED orders.

4.29.6. Travel and per diem expenses of Air Force members from home station MTF to a

referral facility, refer to Section 4C, Patient Travel in this AFMAN.

4.30. Readmission of Patients.

4.30.1. Re-activate an inpatient record of hospitalization if a patient is re-admitted before

midnight (2400 hours) on the same day as previously discharged only if the re-admission is for

the same diagnosis or reason documented during the initial admission process. The attending

provider annotates the reason for re-admission and the hospitalization is considered as one

continuous period.

4.31. Canceling Admissions. Annotate the admission work sheet with the reason for cancellation

and gather all paperwork generated by the admission (e.g., History and Physical, progress notes,

laboratory and x-ray reports, etc.) as one package. Scan/upload into the patient’s electronic health

72 AFMAN41-210 10 SEPTEMBER 2019

record or mail the package to the MTF where the patient’s outpatient medical record is normally

maintained.

4.32. Inpatient Disposition Procedures.

4.32.1. Discharge to Duty (Military Patient) or Discharge (Non-military Patient).

4.32.1.1. Review the AF Form 577, Patient’s Clearance Record, to ensure the patient has

cleared all necessary sections. Annotate the form with the date and time of discharge and

enter the information into the current automated system. The patient is then released from

the MTF.

4.32.1.2. Maintain the AF Form 577 in the Admissions and Dispositions Office for a

period of three months and then destroy.

4.32.1.3. Remove any pertinent information from the suspense file and scan/upload in the

patient’s electronic health record.

4.32.2. Discharging Non-AD Patients Requiring Domiciliary or Custodial Care.

4.32.2.1. Discharge retirees eligible for care in VA facilities as follows:

4.32.2.1.1. Arrange for admission and transportation to a VA medical facility, if

acceptable to the patient or legally authorized representative.

4.32.2.1.2. Release retirees declining assistance in getting into a VA facility to the

legally authorized representative.

4.32.2.1.3. If the legally authorized representative declines acceptance, contact civil

authorities in the patient’s state of residence for permission to transfer the patient to

their custody. If the original request for permission is disapproved, contact the

servicing legal office for assistance.

4.32.2.1.4. Provide complete information from the attending healthcare provider (in

narrative form) on the diagnosis, date the condition started, history of previous

hospitalization(s) for the condition, patient’s legal residence, place and date of birth,

length of patient’s military service, and name and address of patient’s legally

authorized representative.

4.32.2.1.5. Coordinate the patient’s move, with proper escort, to the legally authorized

representative or to the civilian authority accepting custody. Advise the accepting party

of the expected time of patient’s arrival.

4.32.2.2. Discharge other non-AD patients requiring domiciliary or custodial care

following procedures similar to those in paragraph 4.31.1 and 4.31.2.1.

4.32.2.2.1. Discharge alternatives must be acceptable to the patient or the legally

authorized representative. (T-3).

4.32.2.2.2. Release the patient to the legally authorized representative if the arranged

or recommended alternatives are declined.

4.32.2.2.3. Request permission to transfer patient custody to civil authorities if the

legally authorized representative declines acceptance. Contact the Staff Judge

Advocate if the request is denied.

AFMAN41-210 10 SEPTEMBER 2019 73

4.32.3. Discharging Patients Not Eligible for Care at VA Expense.

4.32.3.1. Discharge a military patient who, upon expiration of term of service, has physical

or mental disabilities and requires custodial care or is not competent to care for themselves

as follows:

4.32.3.1.1. Contact the legally authorized representative to determine whether they are

assuming custody of the patient and responsibility for care.

4.32.3.1.2. The legally authorized representative must produce affidavits certifying

their willingness to make suitable arrangements for the patient and the financial means

to do so.

4.32.3.1.3. See 4.32.2.1.3 – 4.32.2.1.4 for procedures to follow when the legally

authorized representative declines acceptance.

4.32.3.1.4. Coordinate the patient’s move, with proper escort, to the legally authorized

representative or to the civilian authority accepting custody. Advise the accepting party

of the expected time of the patient’s arrival.

4.32.3.2. When the patient is stable enough, transfer a federal civilian employee patient

with a physical or mental disability requiring hospital care that exceeds the MTF’s

capabilities or if the civilian employee is not a beneficiary under the Federal Employee’s

Compensation Act. Coordinate proposals to move a civilian employee hospitalized in a

medical facility outside the United States, or when it is necessary to separate the employee

from Federal service for medical or other reasons, with the appropriate Civilian Personnel

Office.

4.32.4. Discharging Patients with Chronic Physical or Mental Conditions. The following

instructions apply to a civilian or military member who is separated or retired because of a

chronic physical or mental condition.

4.32.4.1. A patient who does not exhibit suicidal or homicidal tendencies may request

release to the legally authorized representative. See 4.32.3.1.2.

4.32.4.2. Discharge a patient who exhibits suicidal or homicidal tendencies as follows:

4.32.4.2.1. Transfer a member or former member of the Uniformed Services entitled

to treatment by the VA to a location designated by the VA. This requires the request

of the legally authorized representative and authorization for admission from the

hospital concerned. A patient with a mental health condition requiring inpatient

hospitalization may be eligible for involuntary inpatient admission pursuant to

applicable state law.

4.32.4.2.2. Discharge a military or civilian patient not entitled to treatment by the VA

to civil authorities who are legally authorized to assume care in such case; or to an

acceptable private hospital at the written request of the legally authorized

representative. This will also require authorization from the destination hospital. (T-

1).

4.32.4.3. A non-military psychotic (mental disorder) patient admitted to an Air Force MTF

overseas is handled by the liaison, through the American Embassy and civil authorities, to

resolve problems associated with hospitalization and transfer to CONUS.

74 AFMAN41-210 10 SEPTEMBER 2019

4.32.4.3.1. By law, the Department of Health and Human Services may receive and

provide care for non-military mental health patients returned to CONUS.

4.32.4.3.2. If the patient is not releasable to the legally authorized representative, and

is not authorized further Air Force hospitalization, the overseas commander should ask

local United States diplomatic representatives to arrange, through the Department of

State, for the Department of Health and Human Services to receive the patient upon

arrival in CONUS.

4.32.5. Disposition of Prisoner Patient. When discharging prisoner patients, Federal Bureau

of Prisons exercises administrative control over prisoners confined in a DoD regional or long-

term corrections facility. This agency’s responsibility extends to all matters except clemency,

parole, restoration to duty and enlistment. When a prisoner is under the administrative control

of the Air Force, the Air Force is responsible as follows:

4.32.5.1. If a prisoner, whose sentence includes an executed punitive discharge, has a

disabling condition (including psychosis requiring closed unit treatment), hospitalize the

prisoner at the nearest DoD hospital which can provide the required care. Move the patient

in accordance with AFI 31-105, Air Force Corrections System.

4.32.6. Discharging Patients with Communicable Diseases. Notify Force Health Management

if a patient has a communicable disease when the term of service ends and if the patient elects

to separate and be discharged from the hospital.

4.32.7. Discharging Non-AD Patients Refusing to Comply with Rules. Contact the Staff

Judge Advocate for assistance when a non-AD patient fails or refuses to comply with

established patient behavior rules in paragraph 2.19.4.

4.32.8. Discharging Patients with Terminal Illness.

4.32.8.1. Transfer non-Air Force members according to the latest joint service

medical/patient regulating guidance.

4.32.8.2. Final decision on the discharge of the patient depends on MTF capability,

demand for services and humanitarian considerations.

4.32.8.3. If the AD terminal patient is referred to the Physical Evaluation Board, follow

the procedures in Section 4K and AFI 36-3212.

4.32.9. Discharging Patients Absent Without Leave (AWOL). Report a military patient who

is AWOL from a medical facility to the individual’s servicing Military Personnel Section. Do

not carry AWOL patients on the Admissions and Dispositions Office list or the census reports

more than 10 days. Close out the medical records after 10 days. Under this section, all

disclosures of PHI to commanders will be tracked in accordance with AFI 41-200. (T-0).

4.32.10. Discharging Patients through action by Medical Evaluation Board and Physical

Evaluation Board. See Section 4K and AFI 36-3212.

4.32.11. Retention of Enlisted or Officer Patients Beyond the Discharge Date. See AFI 36-

3208, Administrative Separation of Airmen.

4.32.12. Discharging Persons Refusing Professional Care. See Section 4K. Notations are

placed in the health record documenting the refusal and explaining the risks of refusal that

were provided to the patient. Beneficiaries are encouraged to sign the notation.

AFMAN41-210 10 SEPTEMBER 2019 75

4.33. Convalescent Leave. Initiate convalescent leave for military patients in accordance with

AFI 36-3003. Convalescent leave is not to be used as an alternative for placing a member in an

excused from duty status or when an individual could instead be returned to limited duty without

adversely affecting full recovery. (T-1).

4.33.1. MTF commanders or directors may recommend convalescent leave up to a total of 90

days for a single period of hospitalization. Convalescent leave over 30 days requires additional

medical review and consent with the exception of obstetrical leave. The MTF’s MAJCOM

command surgeon’s office must approve convalescent leave in excess of 90 days. (T-2).

4.33.2. (Added) Per AFI 36-3003, Military Leave Program, Maternity Convalescent Leave

is limited to a covered Service member birthparent after a qualifying birth event. It is limited

to 42 days of non-chargeable leave, unless additional Maternity Convalescent Leave is

specifically recommended, and must be taken prior to any caregiver leave (for a maximum of

84 days in conjunction with Primary Caregiver Leave). (T-1).

4.33.2.1. In cases where a baby is stillborn, the member suffers a miscarriage/termination,

or where the baby is given up for adoption immediately following birth, unit commanders

will grant convalescent leave, other than Maternity Convalescent Leave, up to 42 days,

based on the patient-specific time of gestational age of the fetus, as noted in Table 4.1,

RECOMMENDATIONS: Convalescent Leave after Perinatal Loss. (T-1).

4.33.2.2. (Added) Table 4.1 provides a guide regarding convalescent leave.

4.33.2.2.1. Provider convalescent leave recommendations shall also be guided by best

clinical judgment, however, they are recommended to be no less than the time periods

as listed in Table 4.1. (T-1).

Table 4.1. (Added) Recommendations: Convalescent Leave after Perinatal Loss

GESTATION

(WEEKS +

DAYS)

CONVALESCENT LEAVE

RECOMMENDATION

PROFILE

RECOMMENDATION

COMMENTS

First Trimester

Less than or

equal to twelve

weeks and zero

days (≤ 12+0)

7 days

60 days no Physical Fitness

Testing (PFT)

With or without

surgical intervention

Second

Trimester

Twelve weeks,

one day to

sixteen weeks,

zero days (12+1

– 16+0)

14 days

180 days no PFT testing

With or without

surgical intervention

76 AFMAN41-210 10 SEPTEMBER 2019

Second

Trimester

Sixteen weeks,

one day to

nineteen weeks,

six days (16+1 –

19+6)

21 days

180 days no PFT testing

In accordance with

DAFI 34-501 and the

commonly used

definition for ‘fetal

death’, if neonate is

>20+0 weeks

gestation OR has a

fetal weight of 350

grams or more,

mother should receive

42 days of

convalescent leave.

In cases of multiple

pregnancies (such as

twins or triplets), if

one fetus meets the

fetal weight of 350

grams or more,

mother should receive

42 days convalescent

leave).

Second

Trimester

Twenty weeks,

zero days to

twenty seven

weeks, six days

(20+0 – 27+6)

42 days

365 days no PFT testing

Intentionally left

blank

Third Trimester

Twenty eight

weeks, zero days

to term (28+0 –

term)

42 days

365 days no PFT testing

Intentionally left

blank

Baby born alive

at any gestation

42 days

Intentionally left blank

Qualifying birth event

– mother would

AFMAN41-210 10 SEPTEMBER 2019 77

receive Maternity

Convalescent Leave

4.33.3. Recommendations for convalescence are also used for outpatients (without related

inpatient episode) when the medical condition warrants it.

4.34. Reporting AD Soldiers, Sailors, and Marines Hospitalized in Civilian or Non-Military

Medical Facilities.

4.34.1. Upon notification of an AD Soldier, Sailor, or Marine hospitalized in a nearby or

regional civilian or non-military medical facility, the TRICARE Operations and Patient

Administration or Patient Administration Function at the nearest Air Force MTF shall obtain

the patient’s name, rank, unit name and location, and additional identifying data and notify the

nearest Army or Navy MTF, as appropriate, and notify the individual’s unit commander. (T-

3).

4.34.2. Contact the DHA-Great Lakes at 1-888-647-6676 when notified of an AD Soldier,

Sailor, or Marine hospitalized at a local or regional civilian or non-military medical facility.

The Air Force MTF will make every effort to contact the AD service member’s unit

commander. On occasion, the Air Force MTF nearest to the hospitalized Soldier, Sailor, or

Marine may be asked to assume temporary administrative support responsibility. In this event,

TRICARE Operations and Patient Administration personnel at the nearest Air Force MTF shall

initiate the necessary action to keep the designated parent service representative and member’s

unit commander informed of the patient’s status. (T-3).

4.34.3. Coast Guard, United States Public Health Service or foreign military personnel

admitted to civilian or non-military medical facilities are not admitted and/or tracked as

“Absent Sick” definition listed in paragraph 4.22 and are not entered into the current automated

inpatient admission system. Additionally, there is no need to contact the MAJCOM command

surgeon’s office, AFMOA/SGAT, or the Air Force Medical Operations Center at the Pentagon

unless the admitted Coast Guard, United States Public Service or foreign military member

meets the “prominent persons” definition listed in paragraph 4.25.

4.34.4. In any situation where the MTF receives information about any Uniformed Service

Member admitted to a local or regional civilian or non-military medical facility, it is imperative

that the MTF commander, director or designee notify the nearest appropriate sister service

MTF and/or member’s unit commander, first sergeant, or other appropriately appointed

commander’s designee, of the hospitalization.

4.34.5. Admissions and Dispositions Office will notify the base ground occupational office in

accident cases using AF Form 1488. (T-1).

4.34.6. All disclosures of PHI to commanders will be tracked in accordance with AFI 41-200.

(T-0).

78 AFMAN41-210 10 SEPTEMBER 2019

Section 4I—Casualty Reporting Program Administration

4.35. Reporting Patients in Casualty Status.

4.35.1. This section describes patients and MTF reporting procedures for patients placed in a

casualty status in accordance with AFI 36-3002. Categories of patients requiring special

casualty reports are as follows:

4.35.1.1. Very Seriously Ill Patients. A Very Seriously Ill patient requires medical

attention and medical authority declares it more likely than not that death will occur within

72 hours.

4.35.1.2. Seriously Ill Patients. A Seriously Ill patient requires medical attention, medical

authority declares that death is possible, but not likely within 72 hours, and/or the severity

is such that it is permanent and life-altering.

4.35.1.3. Under this section, all disclosures of PHI to commanders will be documented in

accordance with AFI 41-200. Disclosure of PHI associated with the Seriously Ill-Very

Seriously Ill status of Non-AD patients to external MTF agencies (including, but not

limited to, the installation command post or Casualty Affairs office) is authorized only after

obtaining the patient's authorization or as required by law. In situations where the patient

is incapacitated or otherwise unable to agree or object to the disclosure, the MTF may, in

the exercise of professional judgment, make such notification in accordance with AFI 41-

200. All disclosures of PHI must be properly documented in the PHI Management Tool

or AFMS approved disclosure accounting tool. (T-0).

4.36. Assigning Responsibility.

4.36.1. The patient’s attending healthcare provider classifies a patient as Very Seriously Ill or

Seriously Ill and records an entry on the AF Form 3066, Doctor’s Orders, 3066-1, Doctor’s

Orders, or in Essentris. The provider is also responsible for completing the clinical

condition/status portions of the AF Form 570, Notification of Patient’s Medical Status, and

signing and applying signature stamp where required. Additionally, MTF Patient

Administration staff or designated Casualty Affairs Liaison may be required (depending on

local installation Casualty Affairs Office reporting rules) to complete an additional local form

to secure emergency government sponsored travel for an AD patient's immediate family

member(s). The MTF Casualty Affairs Liaison is responsible for submitting all MTF Casualty

reporting forms/documents/information to the installation Casualty Affairs or Casualty

Assistance Representative. At inpatient MTFs, the Casualty Affairs Liaison may be the

Admissions and Dispositions Office supervisor, one or more members of the Admissions and

Dispositions Office staff, and/or the on-call administrative NCO or Officer of the Day. At

outpatient MTFs, the Casualty Affairs Liaison may be the NCOIC, Patient Administration.

4.36.1.1. Preparation of AF Form 570.

4.36.1.1.1. Complete sections I, II, and, III when the report is prepared. Complete

section IV when reporting Seriously Ill and Very Seriously Ill patients. If the patient

is an organ donor, check the appropriate block and indicate organ to be donated. The

Casualty Affairs Liaison will complete section V. Section VI may be used to continue

entries from other sections, provide additional information, or request administrative

action.

AFMAN41-210 10 SEPTEMBER 2019 79

4.36.1.1.2. Upon receiving the AF Form 570, the Casualty Affairs Liaison completes

section V and immediately notifies the installation commander via the command post

and/or Casualty Assistance Representative in accordance with AFI 36-3002. The

Casualty Affairs Liaison provides enough information to make the first notification and

required progress reports on the patient’s status. If the patient has not authorized the

release of their information, ensure only the minimum necessary amount of information

is released and properly documented in the PHI Management Tool or AFMSA

approved disclosure accounting tool.

4.36.2. For AD personnel in a Seriously Ill, Very Seriously Ill, or Not Seriously Ill/Injured

casualty status, the attending physician, MTF commander or director, member’s commander,

or designated representative or AFPC/DPFC notifies the legally authorized representative in

accordance with AFI 36-3002.

4.36.3. If the status of a patient previously reported as Seriously Ill or Very Seriously Ill

changes the attending physician or dentist prepares an AF Form 570.

4.36.4. Regardless of the patient category, document all notifications for Seriously Ill and

Very Seriously Ill status in the appropriate casualty status remarks module/section in the CHCS

or other automated inpatient monitoring and documentation system. The patient must be

admitted and an active inpatient register number must exist before casualty status changes can

be made. (T-1). Document the release of information (for all patient categories) in the PHI

Management Tool or AFMS approved disclosure accounting tool. (T-2).

4.36.5. Absent Sick Patients: The Chief of Medical Staff, designee, or other appropriate

medical authority at the MTF assigned to monitor the civilian medical facility admission,

should contact the member’s attending physician and obtain enough medical information to

determine appropriate Seriously Ill or Very Seriously Ill status (if warranted). If such a

condition exists, an AF Form 570 must be completed by the physician and forwarded to the

office responsible for coordinating with the Casualty Assistance Representative and member’s

unit commander or installation command post. (T-3). If the patient has not authorized the

release of their information, ensure only the minimum necessary amount of information is

released and properly documented in the PHI Management Tool or AFMS approved disclosure

accounting tool. (T-2).

4.37. Requesting and Arranging Travel for Legally Authorized Representative under the

Emergency Family Member Travel Program.

4.37.1. In situations where an AD or RC service member patient in a on duty and/or in-line of

duty status has been placed on the inpatient Seriously Ill or Very Seriously Ill roster, the

attending physician must provide written recommendation to the MTF commander or director

that indicates the presence of the designated travelers is considered beneficial to the patient’s

recovery or when the member’s designated travelers' presence is warranted given the patient’s

critical or terminal prognosis. (T-3). If the MTF commander or director approves the request

(in writing), the Casualty Affairs Liaison or the administrative officer or noncommissioned

officer of the day must immediately contact the installation Casualty Assistance

Representative. (T-3). The Casualty Assistance Representative is then responsible for

coordinating the MTF commander’s or director’s recommendation/approval for Emergency

Family Member Travel Program with Air Force Personnel Center Casualty Affairs officials.

Air Force Personnel Center Casualty Affairs Program management officials are responsible

80 AFMAN41-210 10 SEPTEMBER 2019

for arranging military or commercial transportation arrangements (including commercial

airline travel) for no more than three designated travelers provided all the required legally

authorized representative information is obtainable. A comprehensive explanation of the entire

Emergency Family Member Travel Program is available in AFI 36-3002.

4.37.2. The MTF commander or director or designee must concur and approve the attending

physician’s request on Emergency Family Member Travel Program Request Memorandum

prior to Air Force Personnel Center Casualty Affairs Program securing emergency designated

traveler travel arrangements. (T-3). Prior to approving the Emergency Family Member Travel

Program Request Memorandum, the MTF commander or director or designee must ensure

there are no more than a total of three designated travelers between the Emergency Family

Member Travel Program and Non-Medical Attendant Program. (T-2).

4.37.3. Final emergency designated traveler travel approval is not to be authorized at the MTF.

4.37.4. The Emergency Family Member Travel Program benefit does not apply to Service

academy cadets, high school, college, or university ROTC participants.

4.38. Preparing the AF Form 1403, Roster of Seriously Ill/Very Seriously Ill.

4.38.1. The Casualty Affairs Liaison prepares the AF Form 1403, just after midnight each day

to document the preceding 24-hour casualty status activity period. Negative activity rosters

are not required. Typically, this report is generated automatically or user requested from the

CHCS automated system. Distribute the report internally within the MTF in accordance with

local guidance. External MTF reporting should be limited to the installation Casualty Affairs

office and/or the installation Command Post (in case of Very Important Person reporting).

Report initial Seriously Ill/Very Seriously Ill placement status and again if the status changes

or is removed.

4.38.1.1. Reporting Seriously Ill and Very Seriously Ill status PHI to external MTF

agencies (including, but not limited to, the installation command post or casualty affairs

office) regarding non- AD service member, is generally authorized only after obtaining the

patient’s authorization or exercising professional judgment in the disclosure of relevant

information in emergency situations.

4.38.2. Providing Follow-up Information. The Casualty Affairs Liaison provides the

installation commander and Casualty Assistance Representative with information received

from the patient’s healthcare provider for follow-up action in accordance with AFI 36-3002.

4.38.3. Removing Patients from the Roster.

4.38.3.1. When the attending healthcare provider determines that the patient can be

removed from AF Form 1403, prepare AF Form 570 and send it to the Casualty Affairs

Liaison.

4.38.3.2. The Casualty Affairs Liaison will notify the installation commander and

Casualty Assistance Representative once the patient is removed from the roster so that

action can be taken in accordance with AFI 36-3002, Casualty Services. Notify interested

persons or agencies, as defined by local guidance, quickly and complete Section V of AF

Form 570. File AF Form 570 in the patient’s suspense file. Annotate the remarks section

of the work copy of the AF Form 1403 to indicate the time of removal.

AFMAN41-210 10 SEPTEMBER 2019 81

4.39. Responsibility for Preparing Death Cases. As described in the following paragraphs, the

individual who is responsible for preparing death cases varies depending on the status of the

patient.

4.39.1. Death of a person while being attended outside the MTF: The attending Air Force

medical officer.

4.39.2. Death of a person in an Air Force-owned or leased aircraft: The MTF serving the base

that investigated the accident.

4.39.3. Death of other Air Force personnel who are not patients in a MTF at time of death:

The MTF serving the base that investigated the circumstances of death.

4.39.4. Death of a non-military person on an Air Force base: The MTF serving the base.

4.39.5. Death of a person being staged through an Enroute Patient Staging flight: The MTF

supporting the Enroute Patient Staging Flight.

4.39.6. Death of a person while in transit and in inpatient status: The MTF receiving the

remains. Note: Treat as transfer-in patients those who die while in transit (either while in flight

or in an ambulance between facilities) or while being staged through an Enroute Patient

Staging Flight.

4.39.7. Notwithstanding any other international, federal, state, or county law, or any other

DoD or Air Force Issuance, MTF providers, usually the member’s Primary Care Manager or

specialist, may be asked to sign the death certificates for retired military members or family

members who have died in their off-base homes of natural causes. Check with the wing or

base mortuary affairs office, local county sheriff’s office, or county coroner before preparing

the death certificate or authorizing or obtaining a MTF provider’s signature. Providers should

not document or certify a cause of death unless, based on their knowledge of the patient and

the circumstances of death, they are able to determine the cause of death to a reasonable degree

of medical certainty. Consult with the servicing legal office with any questions or concerns.

4.40. Policies Regarding Deaths.

4.40.1. See AFI 34-501, Mortuary Affairs Program, for instructions on preparing, inspecting

and shipping remains and completing related forms and reports.

4.40.2. A healthcare provider verifies all deaths occurring at an Air Force MTF and on an Air

Force installation.

4.40.3. If a member of the Uniformed Services on AD dies outside the limits of an Air Force

installation, do not remove the body without permission of civil authorities or local coroner.

4.40.3.1. The installation commander consults with the Armed Forces Medical Examiner

System when uniformed services personnel die within installation limits under exclusive

federal jurisdiction. When uniformed services personnel die beyond installation limits the

commander consults local civil authorities to identify procedures to follow.

4.40.3.2. Obtain a transient or burial permit from the proper civil authority before

removing a body from an Air Force base for shipment or burial.

4.40.3.3. Release remains to mortuary personnel within 24 hours after death unless

extenuating circumstances exist. Ensure that the death certificate is completed and signed

82 AFMAN41-210 10 SEPTEMBER 2019

by the responsible medical officer before releasing the remains. The mortuary

representative (military or civilian) taking custody of the remains signs a receipt for the

remains. Scan/upload the receipt in the deceased’s electronic health record.

4.40.4. Initial movement of remains is accomplished as follows:

4.40.4.1. Typically, a provider pronounces death at the site or at the MTF; prepares a death

certificate; and obtains a decision regarding an autopsy. If no autopsy is required, officials

from Mortuary Affairs are responsible for arranging transportation to move the body from

the site or from the MTF to the interment location.

4.40.4.1.1. If an autopsy is required, it must be authorized by the base commander or

by the Armed Forces Medical Examiner System. (T-2). If the local coroner has right

of first refusal (in accordance with applicable state law) to conduct the autopsy and the

local coroner defers to the Armed Forces, the following guidance takes effect (T-2):

4.40.4.1.1.1. For deaths occurring on a military installation, or under federal

jurisdiction, if the MTF on that installation has the capability and capacity to

perform the autopsy, then the MTF is responsible for performing the autopsy. If

the installation MTF does not have the capability or capacity to perform the autopsy

then the installation Mortuary Affairs office is responsible for either arranging

transportation of the body to another MTF where autopsy capabilities exist or

arranging a postmortem examination with a contracted civilian pathologist.

4.40.4.1.1.2. If the death of an Air Force AD service member occurs outside a

military installation, the nearest Air Force installation Mortuary Affairs office is

responsible for arranging transportation of the body from the death site or local

coroner’s office back to the closest MTF with histopathology-autopsy capabilities

or to a contracted civilian pathologist in accordance with local and Air Force

Mortuary Affairs policy. In accordance with AFMAN 65-605V1_AFGM2018-01,

Budget Guidance and Technical Procedures autopsies performed by civilian

pathologists, not employed by the Air Force, are funded using “O&M funds of the

organization to which the deceased was assigned.”

4.40.4.1.2. If an autopsy is required and the local coroner is authorized right of first

refusal to conduct the autopsy and the coroner decides to conduct the autopsy

themselves, officials from Mortuary Affairs are responsible for arranging

transportation to move the body to the coroner and then to interment location. Refer to

AFI 34-501 for more information regarding available postmortem Mortuary Affairs

responsibilities and services.

4.40.4.2. Local civil authorities, namely the local coroner, exercise control over the

movement of remains in the event of an off-installation death. Once the remains of an AD

member are released from the civil authorities, determine if an autopsy will be performed.

If yes, medical personnel provide or arrange transport of the remains to the MTF. If an

autopsy is not required, mortuary services transports the remains to the contract funeral

home or government mortuary. Note: In the event of a military aircraft accident, an

autopsy is usually required and will be funded with Defense Health Program money

regardless of who performs the examination.

AFMAN41-210 10 SEPTEMBER 2019 83

4.40.4.2.1. In the case of a death in a foreign country, refer to any applicable treaty,

Status of Forces Agreement or other international agreement to determine authorization

for autopsy. Reference DoDI 5154.30, Armed Forces Medical Examiner System

(AFMES) Operations.

4.40.4.2.2. In a disaster or multiple death situation, the mortuary officer calls the motor

pool for transportation to move the remains during search and recovery operations.

Remains are placed in body bags for movement.

4.40.5. When a patient dies, notify the Casualty Affairs Liaison or their representative

immediately.

4.40.6. Collect and inventory all personal property of the deceased in the presence of a witness

as soon as possible following the death of any patient. Send personal effects of a military

patient to the summary court officer. Send personal effects of civilians to an executor or

administrator, or (if none appointed) to the nearest legally authorized representative. The

executor, administrator or nearest legally authorized representative, as appropriate, signs the

inventory as a receipt for effects. Scan/upload the receipt in the patient’s electronic health

record.

4.40.7. Certificate of Death. Usually the provider pronouncing death, or other authorized

personnel, prepares a death certificate and sends it to the proper authorities according to state

requirements. However, the death certificate must be signed by a physician with knowledge

of the primary and contributory cause(s) of death. (T-1). This may be the pronouncing

physician, the deceased’s primary physician, or another member of the medical staff with that

knowledge. Scan or upload one copy of the certificate in the deceased patient’s electronic

health record or extended ambulatory record. In overseas locations, prepare DD Form 2064,

Certificate of Death (Overseas), per AFI 34-501.

4.40.8. Reporting Deaths. The MTF commander or director reports deaths as required by AFI

36-3002 when a person dies at an Air Force MTF or enroute to the MTF.

4.40.9. Reporting Stillbirths. Prepare a death certificate and file it as required by state and

civil law. File one copy of the fetal death certificate with the mother’s inpatient record. In the

case of an abortion, send the surgical specimen to the laboratory the same as for other surgical

specimens. Note: Even when not required by state law, a fetal death certificate may be issued

if the legally authorized representative requests the coroner or medical examiner to do so.

4.40.10. Comply with AFI 34-501 when deceased, uniformed services personnel cannot be

identified by local means. Utilize the resources of the Armed Forces Medical Examiner

System to the maximum extent possible to support the identification of remains.

4.41. Performing Postmortem (Autopsy) - Non-Forensic Cases.

4.41.1. Perform a hospital or non-forensic postmortem only with the consent of the legally

authorized representative, person(s) having a right of burial, or at the request of the local

coroner or medical examiner (except in the circumstances described in paragraph 4.40.4). Scan

or upload the authorization to perform a postmortem examination in the deceased’s electronic

health record.

4.41.2. Under normal circumstances, complete the postmortem within 24 hours after the

remains are received, appropriate records are available and authorization has been granted.

84 AFMAN41-210 10 SEPTEMBER 2019

4.41.3. Record the postmortem on SF 503, Medical Record-Autopsy Protocol, except those

performed under AFI 91-204. Scan and upload the original copy in the electronic health record

of the deceased. Maintain a completed copy of the certificate in the clinical laboratory.

4.41.4. A death, military or civilian, is a medical examiner case subject to forensic autopsy

when it meets the criteria listed under DoDI 5154.30. These cases do not require consent from

the legally authorized representative. If the death meets any one of the criteria listed in DoDI

5154.30, it must be referred to the Armed Forces Medical Examiner System. (T-0). The Armed

Forces Medical Examiner System may be contacted 24 hours a day, seven days a week at

commercial 302-346-8648. Reference DoDI 5154.30.

4.41.5. Authorization for Postmortem on United States Uniformed Services Personnel. The

installation commander or Armed Forces Medical Examiner is the approving authority for the

postmortem examinations in areas exclusive to Federal jurisdiction and in other areas when the

civil authority has released jurisdiction to the Uniformed Services. In areas outside the United

States and its Territories, existing Status of Forces Agreements apply. When the host

government relinquishes its authority, the Armed Forces Medical Examiner or installation

commander authorizes the postmortem. This approving authority may be delegated to the

MTF commander or director, but must be written and always current. (T-2).

4.41.6. Performing a Postmortem Examination on a Civilian.

4.41.6.1. Obtain the written, signed permission of the nearest legally authorized

representative, or an order by an appropriate civil or military authority if the death occurred

in unusual or suspicious circumstances. Develop procedures incorporating the

requirements of this instruction, relevant laws, existing legal agreements and other

requirements of local authorities.

4.41.6.2. For postmortem purposes, treat the remains of members of the National Guard,

Reserve Officers Training Corps and other RCs not on AD for training, as civilians.

4.41.6.3. When consent of the legally authorized representative is required, check to verify

notification and obtain the required consent on SF 523, Medical Record-Authorization for

Autopsy.

4.41.6.4. After deliverance of casualty notice to the family or legally authorized

representative and confirmation of its receipt, the MTF commander or director sends a

condolence letter to the family or legally authorized representative and requests permission

for a postmortem. The consent is scanned/uploaded in the patient’s electronic health

record.

4.41.6.5. At overseas installations, request the family or legally authorized representative

send the reply to the request for postmortem consent to AFMOA/Chief of Medical Staff.

Upon receipt of reply, AFMOA/Chief of Medical Staff will send a priority wire through

military message channels advising of the decision and then send the original message by

mail to the MTF for scanning/uploading into the patient’s electronic health record. (T-2).

4.41.7. Performing a Postmortem Examination on Foreign Military Personnel. When

performing a postmortem examination on foreign military personnel, obtain permission from

the military attaché of the foreign embassy. Include this request for permission in the casualty

report required by AFI 36-3002.

AFMAN41-210 10 SEPTEMBER 2019 85

4.41.8. Organ Disposal Following Postmortem. Return all organs and tissues removed during

postmortem to the body, except those organs, tissues and tissue fluids essential to diagnose the

cause of death or intended for studies authorized by the family or legally authorized

representative or required by law (see DoDI 6465.03, Anatomic Gifts and Tissue Donation).

4.42. Disposition of Outpatient Records on Deceased AD Personnel. See AFI 36-2608,

Military Personnel Records System and AFI 36-3002 for guidance on the disposition of the

outpatient record when an AD member of the United States Armed Services expires.

4.43. Deceased Patient Kit.

4.43.1. Local or state law may require the local medical examiner or coroner to respond for

each fatality that occurs on a military installation.

4.43.2. The response may include managing, reviewing or pronouncing death in these cases.

Sometimes these responsibilities are deferred to the installation MTF. Such deferrals are more

likely when no suspicious circumstances exist that require an investigation by the local medical

examiner or coroner. These deferrals are also more likely when the MTF has histopathology

or postmortem examination capability.

4.43.3. When practical and only when approved by the appropriate installation Plans,

Programs, and Operations officials, the MTF may enter into a support agreement with the local

medical examiner or coroner and the installation Mortuary Affairs office. Any agreement

should identify specific forms and instructions necessary to process a deceased body.

4.43.4. To adequately prepare for any contingency, each non-bedded Air Force MTF is

required to compile and maintain at least five pre-positioned death processing packages. Each

package will contain all of the forms and documents (described below).

4.43.5. When the MTF is required or authorized to officially respond and process a human

being’s death occurring on a military installation, each package will be used to document the

fatality whether the death occurred in the MTF or elsewhere on the military installation.

4.43.6. Inpatient MTFs will maintain a minimum of ten packages. The packages should be

kept in a central location such as the TRICARE Operations and Patient Administration Flight,

Admissions and Dispositions Office, or the emergency department. Each package shall

contain, at a minimum, the following forms. (T-1).

4.43.6.1. SF Form 523.

4.43.6.2. AF Form 146, Death Tag.

4.43.6.3. AF Form 570.

4.43.6.4. Release of Remains.

4.43.6.5. Request for Postmortem Examination.

4.43.6.6. AF Form 1122, Personal Property and Personal Effects Inventory.

4.43.6.7. Fax Notification.

4.43.6.8. Death Certificate Worksheet.

4.43.6.9. Death Certificate (Issued by state. If overseas use, DD Form 2064).

86 AFMAN41-210 10 SEPTEMBER 2019

Section 4J—Birth Registration Program Administration

4.44. Birth Registration in the CONUS.

4.44.1. A birth certificate will be prepared for each infant born in an Air Force MTF. Follow

State laws with regard to the forms used, format, and number of copies required.

4.44.2. Updating Personnel Records. Advise parents to report to the Military Personnel

Section to update personnel records and register the child in DEERS as part of birth

registration. This must be accomplished within 120 days or the member will receive a bill for

care. (T-3). When both the parents are AD, recommend that the same sponsor be identified in

CHCS and DEERS in order to eliminate confusion with the records.

4.44.3. Refer parents to the TRICARE customer service phone number for TRICARE options,

including TRICARE Prime enrollment.

4.45. Registering Births Overseas.

4.45.1. Overseas Air Force MTFs must cooperate with consular officers in registering births

of infants born to United States citizens in areas overseas. (T-0). Exceptions: Register births

in American Samoa, Guam, Puerto Rico, the Trust Territories, and the United States Virgin

Islands through the special offices of the Vital Statistics Division, Public Health Services,

United States Department of Department of Health and Human Services, or specified local

United States Government offices.

4.45.2. Completing Department of State Form DS-2029, Application for Consular Report of

Birth Abroad of a Citizen of the United States of America, available at

https://eforms.state.gov/Forms/ds2029.pdf. The form DS-2029 will be completed in four

copies. The (U.S. citizen) parent will sign each copy of the forms under oath before a military

officer qualified to administer oaths. (T-0).

4.45.3. If the mother is not a U.S. citizen, the U.S. citizen father must sign form DS-2029 if

he is available. (T-0). If the father is not available (or if there is any question about his

citizenship status), ask the parent(s) to get in touch with the U.S. Consular Office. (T-0).

4.45.4. Registration of Birth. Advise the parents that a fee for registering the child’s birth will

be charged. The U.S. Consular Officer issues them a copy of the Department of State Foreign

Form FS-240, Consular Report of Birth Abroad when the birth is reported, available at

https://travel.state.gov/content/travel/en/international-travel/while-abroad/birth-

abroad.html.

Section 4K—Medical Evaluation of Service Members for Continued Military Service

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Section 4L—Tumor Registry Program Administration

4.74. The Tumor Registry Program.

4.74.1. All Air Force MTFs will maintain a tumor registry of reportable diagnoses (a condition

of malignancy, precancerous lesion, benign central nervous system, brain tumor, or certain

hematopoietic conditions). (T-1). All Air Force MTFs that diagnose and/or treat patients with

reportable diagnoses must have a cancer program or cancer reporting process (for Reporting

MTFs) and will comply with the requirements of the American College of Surgeons’

Committee on Cancer (ACoS CoC). (T-1). The Cancer Program, in accordance with AFI 44-

110, The Cancer Surveillance Program, is based on the size and services of the facility. The

guidance in this chapter applies to Patient Administration only if the MTF is not authorized its

own histopathology department and is thus referred to as a Reporting MTF.

4.74.2. The Reporting MTF will perform a case finding function and report all new cancer

cases to its lead Regional Cancer Registry monthly. (T-1).

4.74.2.1. MTFs in multi-service markets may establish a memorandum of understanding

with Army or Navy MTFs and will be coordinated with the Air Force Cancer Registry

Consultant. (T-1).

4.74.2.2. Case finding may be performed by working a query of reportable diagnosis codes

as well as review/obtain available pathology, radiology, procedure/operative, and other

appropriate reports.

4.74.2.3. Ensures all new cancer cases, including TRICARE beneficiaries who are

diagnosed and/or treated in civilian facilities, are reported.

4.74.2.4. Cancer case information will be transmitted from the Reporting MTF to the

Regional Cancer Registry via encrypted e-mail reports or other HIPAA compliant methods.

(T-1).

4.74.3. The Tumor Registry is the principal database for evaluating the care of cancer patients

in the MTF. Patient Administration actions will include:

4.74.3.1. Use of Automated Central Tumor Registry to create and track cases. Requests

for Automated Central Tumor Registry access (limited to cancer registry personnel) are

made through the Air Force Cancer Registry Consultant.

4.74.3.2. Reporting MTFs retain the responsibility for maintaining follow-up information

for the lifetime of each cancer patient according to American College of Surgeons’

guidelines.

4.74.4. Data requests for research using Automated Central Tumor Registry reports are routed

through the Air Force Cancer Registry Consultant.

4.74.5. Release of Information to Non-Air Force Tumor Registries. Refer to Section 4A on

health information release procedures and requirements.

98 AFMAN41-210 10 SEPTEMBER 2019

Chapter 5

HEALTH RECORDS MANAGEMENT

Section 5A—General Program Administration

5.1. Managing Health Records.

5.1.1. Health records are the property of the United States Government, not the individual

beneficiary. This designated record set consists of electronic health records, outpatient records,

inpatient records, extended ambulatory records, fetal monitor strips, mental health records,

dental records, obstetrical and gynecological (pre and post-partum records), radiographic

images and film, and any other official record or media format (physical, analog, digital, video)

that provides a permanent record of a patient’s medical or dental care. Maintenance of records

at the MTF is required in accordance with this AFI. Refer to Army Regulation (AR) 40-66,

Medical Record Administration and Healthcare Documentation for additional information on

United States Army health records maintenance. Refer to Manual of the Medical Department

(MANMED), NAVMED P-117, Chapter 16, Health Records for additional information on

health records maintenance of Navy personnel. Inform beneficiaries of this requirement

through appropriate media. Initiate action to retrieve records maintained outside the MTF.

Regardless of the status of the individual, if the beneficiary is enrolled to the MTF, it is

mandatory that their health records are maintained in the MTF of enrollment. (T-0). Reference

DoDI 6040.45 and DHA Interim Procedures Memorandum 18-018, Physical Custody and

Control of the DoD Health Record.

5.1.2. Management of medical records includes quality and security assurance which is the

responsibility of administrative, clinical, and information technology staff.

5.1.3. MTF Commander or Director. The MTF commander or director will serve as Custodian

of Records and ensure that all health records are prepared, maintained, used, protected, and

controlled as required in accordance with this manual. (T-2).

5.1.3.1. Ensures that records and loose documents are retired or disposed of according to

the Air Force Records Information Management System (AFRIMS), Records Disposition

Schedule.

5.1.3.2. Must be knowledgeable concerning the control of health records and protected

health information (PHI), release of information from the records, and provider of care

documentation requirements. Commanders ensure that these important functions are

properly supported.

5.1.3.3. Manages custody and control, and security assurance of paper-based and

automated or electronic medical records.

5.1.4. Chief of Dental Services. The Chief of Dental Services serves as the custodian of the

dental records and is responsible to the MTF commander or director for dental record

management functions including custody, control and security assurance of paper-based and

automated or electronic dental records.

5.1.5. Healthcare Providers. Healthcare providers (physicians, dentists, and other authorized

healthcare providers) will include in appropriate health records, an accurate, legible, and

AFMAN41-210 10 SEPTEMBER 2019 99

complete description of all services rendered to patients. (T-2). This description must

adequately address current medical, administrative, and legal requirements. (T-1). Ensure that

proper identification information is entered on various forms and that records are returned to

the appropriate file as quickly as practical, but no later than 72 hours after treatment is rendered.

Note: Dental encounters should follow guidance as outlined in AFMAN 47-101, Managing

Dental Services.

5.1.6. Records created and maintained at a joint DoD/VA facility are shared by the two

organizations. Develop local policies to ensure that the needs of both organizations are met.

Records disposition instructions can be found at the AFRIMS System Records Disposition

Schedule website: https://www.my.af.mil/afrims/afrims/afrims/rims.cfm, the Medical

Record Tracking, Retirement and Retrieval User Guide is located at the AFMS Knowledge

Exchange.

5.2. Documenting Health Records. Health records are completed to meet the highest possible

standards of completeness, promptness, clinical pertinence, and standards of the Joint

Commission. The Joint Commission accredits and certifies nearly 21,000 health care

organizations and programs in the United States. Only authorized individuals make entries in the

original hard copy medical record using black or blue-black ink. No other annotations are

authorized. For care received outside of the Direct Care System ensure that the memorandum of

understanding and TRICARE contracts include a mechanism for obtaining documentation (i.e.,

summaries, operative reports, etc.) to be incorporated into the individual’s health record.

5.3. Correcting Health Records.

5.3.1. Patients have the right, under HIPAA and the Privacy Act, to access their health records

and request amendment if they think the documentation is in error. However, there is no

requirement for the MTF to agree to the proposed amendment. Furthermore, at no time should

any documentation be removed from the record (including automated record documentation

systems) unless it is determined that the documentation does not pertain to the patient in

question or any one of the following applies:

5.3.1.1. Records or Primary Care Manager support staff may remove an outdated DD

Form 2766C as long as the most current version of this form documents the latest

immunization history for the patient.

5.3.1.2. Outdated or expired DD Form 2992, Medical Recommendation for Flying or

Special Operational Duty and AF Form 1418, Recommendation for Flying or Special

Operational Duty – Dental with recommendations for special operations and/or flying

status in accordance with Attachment 8.

5.3.2. The request to amend any part of the health record (electronic or paper) must be made

in writing and be signed by the patient or authorized representative and filed in section 3 of AF

Form 2100A, Health Record - Outpatient or left side of AF Form 2100B, Health Record -

Dental. (T-1).

5.3.3. Refer to AFI 33-332 and AFI 41-200 for response timeline.

5.3.4. Denial of requests is allowed if any of the following conditions are met:

5.3.4.1. The PHI is not part of a designated record set available for inspection under

HIPAA or a system of records under the Privacy Act.

100 AFMAN41-210 10 SEPTEMBER 2019

5.3.4.2. The information requested to be amended is accurate and complete.

5.3.4.3. The MTF did not originally create the PHI requested for amendment (e.g., copies

of records from treatment at another MTF or civilian facility provider). However, if the

requestor can prove that the MTF that originally created the information no longer exists,

the MTF will handle the request as if it had created the information.

5.3.5. Upon receipt of a request for record amendment, forward it immediately to the

applicable provider for research.

5.3.6. If an error is identified and the responsible practitioner is available and recalls the

circumstances, for paper records:

5.3.6.1. Line through the incorrect data with one straight line. Do not erase, scratch out or

otherwise destroy the original data. Amendment of erroneous data should be done by the

initial provider or practitioner. If that is impractical, enter a brief explanation of why the

originating provider did not make the correction. Enter the correct data next to the lined

through data if space permits. Only privileged providers, authorized to document patient

care, will make corrections. Each supplemental or corrected entry must be dated, signed

and stamped. (T-1).

5.3.6.2. If there is not enough space on the record next to the incorrect data to enter the

correction, draw one straight line through the entry, initial, date and make a referral note

to where in the record the correction is documented. Then enter the correction

chronologically as indicated on the referral note. If the correction is not self-explanatory,

also enter the reason for the correction. Provider will sign, date, and stamp the new entry.

(T-1). If other practitioners are associated with the patient’s care and have a need-to-know

concerning the change, inform them of the correction. Major changes may require

documentation on a separate form (i.e., a new, blank form). Follow the same procedures

stated above and file the corrected information as near as possible to the document

containing the lined through information.

5.3.7. If an error is identified after a claim or lawsuit has been filed or after a substantial lapse,

then the provider with personal knowledge of the erroneous data must consult Air Force legal

counsel prior to correcting an erroneous entry in accordance with paragraphs 5.3.6.1 and

5.3.6.2 (T-0). The provider with personal knowledge of the erroneous data should immediately

notify all practitioners involved with the patient’s care.

5.3.8. Patients who believe their medical records contain erroneous entries or information

have several options to remedy perceived errors. Several instructions, such as AFI 33-332 and

AFI 36-2603, Air Force Board for Correction of Military Records (AFBCMR), allow patients

to seek relief when they believe their medical records should be amended and the MTF has

denied their requests. If a patient files such a request to the Air Force Board of Correction of

Military Records, SAF/MRBR, 550 C Street West, Suite 40, Randolph Air Force Base TX

78150-4742, the MTF will take no action until contacted by the board representatives. See

AFI 36-2603 Chapter 3 for application procedures and who may apply. If there are questions

regarding an amendment, contact the Staff Judge Advocate or area medical law consultant.

5.3.9. MTF should ensure careful adherence to the process of legal corrections of erroneous

data or information in a patient’s electronic health record. Legal corrections of erroneous data

may require Tier III Help Desk Support. Tier III Help Desk Support is a resource external to

AFMAN41-210 10 SEPTEMBER 2019 101

the MTF that handles advanced technical issues. Defense Health Agency (DHA) has

developed a specific process to request the legal correction of erroneous PHI in situations

where the incorrect information identifies another individual and the MTF is not able to make

the correction at the local level. This direction is located in the "Policy for Legal Correction

of AHLTA Erroneous Data or Information” and the process is contained in updated guidance

found on AFMOA Health Benefits Kx at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

5.3.10. All provider Social security numbers must be redacted and made unreadable prior to

issuing a copy of any health record (including, but not limited to, the outpatient medical, dental

treatment, inpatient, ambulatory procedure visit, and extended ambulatory record). (T-2).

Specifically, the MTF will make an initial copy of the record(s), then within the copy, sanitize

the entire Social security number, and then recopy the health record(s) before releasing a copy

to the requestor. This policy applies to copies for any purpose, to include individual’s

requesting copies of the individual’s own records for any reason. Original medical records

should remain intact. The original provider’s social security number must never be deleted

from the original health record. (T-0).

5.4. The Electronic Health Record.

5.4.1. Since 2006, the AFMS has used AHLTA; the Department of Defense’s (DoD) approved

electronic health record for the day-to-day outpatient care documentation processes. Until

completely transitioned to an electronic health record, the AFMS will use a hybrid record

consisting primarily of the electronic health record and include traditional paper-based records

and forms to meet unique operational mission requirements.

5.4.2. The following applications are the only approved electronic health record applications

authorized for use within the AFMS:

5.4.2.1. AHLTA and CHCS – outpatient medical and dental care which is stored in the

Central Data Repositories.

5.4.2.2. Essentris – inpatient medical care which is stored in the MTF Global Data

Repositories.

5.4.2.3. Composite Health Care System (CHCS) II-Theater (Armed Forces Health

Longitudinal Technology Application-Theater (AHLTA-T)).

5.4.2.4. Health Artifact and Image Management Solution (HAIMS) – enterprise-wide data

sharing capability for all types of artifacts and images.

5.4.2.5. Military Health System (MHS) GENESIS – new electronic health record for MHS

providing a single health and dental record for beneficiaries.

5.4.3. Medical Systems and Applications Not Considered Part of the Official Air Force

Medical System electronic health record:

5.4.3.1. Unless approved by competent authority, MTFs may not acquire, deploy or use

electronic health record systems other than those described in paragraph 5.4.2. This

prohibition applies to applications, systems or components of electronic health records

intended to temporarily or permanently document patient healthcare. Competent authority

resides with the Assistant Surgeon General, Health Care Operations; the Air Force Surgeon

102 AFMAN41-210 10 SEPTEMBER 2019

General (or deputy); or officials of the Office of the Assistant Secretary of Defense, Health

Affairs (ASD/HA).

5.4.3.2. Any non-AFMS or non-MHS standardized electronic system, application, or

clinical management tool is not considered part of the official Air Force electronic health

record. The documents contained within these tools are not considered part of the

electronic health record. To be approved for use, these tools must provide for the

permanent transferability of electronically generated or documented health information

into the following:

5.4.3.2.1. MHS Central Data Repositories,

5.4.3.2.2. Individual or regional MTF inpatient Global Data Repositories,

5.4.3.2.3. MHS or Air Force standardized and approved data repository or database,

5.4.3.2.4. Official VA single medical data repository. (T-1).

5.4.3.3. If the clinical information and/or PHI contained therein is meant to be permanently

stored or may possibly be relied upon in the future to support the delivery of healthcare,

then all PHI must be immediately transferred to an approved electronic health record or

standardized and AF/SG approved data repository or printed and scanned into HAIMS. (T-

1).

5.4.4. MTF commanders or directors may require that all or some of the medical records

maintained within the MTF be filed in hard copy format, regardless of electronic health record

capabilities, to fulfill mission requirements and to ensure comprehensive continuity of care.

MTF commanders or directors must be knowledgeable of health record management practices

as they apply to members assigned to the Sensitive Duties Programs. (T-2).

5.4.5. Service Members assigned to Sensitive Duties may be temporarily or permanently

decertified, suspended, or removed from their duty position(s). This determination may be

based on their medical, dental, mental health status, or the type of medications prescribed.

Sensitive duties programs include the Personnel Reliability Assurance Program, Presidential

Support Program, or other sensitive duty national security program(s). The current DoD

electronic health record cannot automatically provide for the mandatory notification and

receipt confirmation documentation. Notification must occur between the MTF competent

medical authority and individual unit commanders or installation operational assurance

officials. (T-1). This notification must include the service member’s health status, operational

capabilities/limitations, or fitness for duty following each patient encounter. (T-1). Following

proper notification and documentation (either electronic or written), all documents will be

uploaded into the service member’s outpatient medical electronic health record via HAIMS or

filed in the dental treatment record. (T-1).

5.4.6. The combination of the electronic health record and the paper record constitutes a

complete health record for a beneficiary and both record types need to be available for

inspection, review, and copying when required. Failure to maintain the paper medical record

as outlined in this instruction will result in a program deficiency and may violate HIPAA

safeguard requirements, Air Force Inspection Agency and Joint Commission standards.

5.4.7. Prior to a beneficiary’s Permanent Change of Station (PCS) reassignment, personal

geographic location move, MTF reassignment, or change to TRICARE enrollment location,

AFMAN41-210 10 SEPTEMBER 2019 103

all laboratory and radiology CHCS results, must be printed and filed into the patient’s health

record. (T-2). Since AHLTA is operational at all Active Duty (AD) MTFs, MTF health records

personnel are not required to print AHLTA patient encounter notes. However, if a beneficiary

is moving or has a PCS to a remote location without access to AHLTA, then all historical

AHLTA patient encounter notes must be printed and filed into the patient’s health record. (T-

1).

5.4.8. MTF personnel must establish procedures to provide beneficiaries copies of their

medical documentation from their electronic record when requested. (T-0). The format of the

documentation can be either paper or electronic; whichever is acceptable by the beneficiary.

If the documentation is provided in electronic format, MTF personnel must ensure their facility

is in compliance with the HIPAA, and any revisions to DoDM 6025.18 regarding modes of

transmission to the beneficiary. (T-0). Refer to AFI 41-200, paragraph 7.6 for additional

information.

5.4.9. Documenting MTF Healthcare in AHLTA (Minimum Operational Rules).

5.4.9.1. It is a prohibited activity to enter, upload, or transfer information, documents, files,

or images to the electronic health record that would not normally be available to patients.

Examples of these inappropriate entries are documents created or governed by quality

assurance, business rules, including peer review results or any Quality Assurance related

information; root cause analysis or other information not normally considered part of a

medical record. Information of this type will not be entered or uploaded into the Central

Data Repositories. (T2)

5.4.9.2. The operational processes listed herein were current at the time of this publication.

Advances in technology often outpace policy development; therefore this policy attempts

to outline rules of the current technology and to clarify operating parameters when

advances occur. This manual also includes actions for moving to an electronic

environment (1) the paper record is only retrieved by exception, (2) the filing of all paper

documents is eliminated, and, (3) when to “retire” or disposition paper records. These

actions include firm policy guidance. When certain milestones are reached, a specific set

of actions must occur.

5.4.9.3. The development of alternative plans independent of AF/SG and/or DoD

guidelines is not authorized without permission from AF/SG3. Alternative data capture

and documentation methods not originally identified or engineered for permanent storage

into the Central Data Repositories, are not authorized without approval from AF/SG3. Any

other use of technology contrary to guidance provided in this manual must be discontinued

until permission is granted for process continuation. (T-2). Forward all requests for

permission to depart from these operational rules to AFMSA/SG3S. Exceptions must

clearly state why the facility cannot change to an approved methodology. (T-1). Waiver

requests will be considered with a global or Service-wide standardization impact

perspective. (T-1).

5.4.9.4. Every Air Force MTF will use AHLTA or approved electronic health record to

document outpatient care. (T-1). All outpatient MTF entries (except emergency

department entries and dental treatment entries) must be entered into AHLTA. (T-1). Use

of structured text within approved electronic health records is highly encouraged. As other

automated methods of entry become available, these processes will likely be authorized

104 AFMAN41-210 10 SEPTEMBER 2019

following analysis by AF/SG3. Clinical data collection and document template use is

encouraged, using AHLTA capabilities to leverage documentation technique.

5.4.9.5. Printing AHLTA Information and Encounters. Printing and filing of patient

encounters stored in AHLTA is not required. Exception: Until further notice, all

information in AHLTA for non-service treatment records must be printed and filed prior

to disposition of the medical and dental record before physically mailing the record(s). (T-

1). Any automated clinical encounters, results, or notes that a provider feels a patient would

need or benefit from are authorized to be printed during a patient visit and handed to the

patient.

5.4.9.6. Electronic/Digital File Types and Files Size. Use only the following electronic

file types when capturing documents, files, or images into an AHLTA patient encounter

note: TXT, RTF, HTML, TIF, JPG, BMP, and DOC. Note: PDF files cannot be directly

uploaded into AHLTA; however, the information contained within a PDF file may be

copied and pasted into the “Add Note” using the Adobe Reader Snapshot tool. Imported

documents, files, or images will not exceed 500kb.

5.4.9.7. Placement of Scanned/Uploaded/Imported Documents, Files, and Images into

AHLTA.

5.4.9.7.1. Within a patient encounter note: A scanned document, file, or image may

be uploaded or imbedded into an AHLTA patient encounter note, provided the

document or image a) is directly related to the current patient encounter, b) will not

delay the coding of the patient encounter note, and c) can be uploaded into the patient

encounter note before the provider electronically signs the encounter. By signing the

encounter, the provider is acknowledging that the scanned/uploaded image or

document was acceptable for its intended purpose.

5.4.9.7.1.1. Appending a patient encounter note after the note is Closed/Signed. If

the document cannot be imbedded into the note before the provider electronically

signs, or if an image is captured, or scanned and uploaded in support of a previous

episode of care, the document or image should be appended to the desired note.

This action will generate an automatic notification to the provider or user who

created the original encounter note. The notification mechanism lets the original

creator know that someone has appended the member’s original patient encounter

note.

5.4.9.7.1.2. Appending a previously closed encounter with an uploaded image will

not change the original encounter information. The user adding the additional

image or document must also electronically sign the appended patient encounter

notes. (T-2). Appending a note is a permanent action and cannot be reversed.

Appended documentation is not searchable. Without prior knowledge that a

specific encounter note has been appended with an image, subsequent users may

have significant difficulty finding the appended image or they may not even know

of its existence.

5.4.9.7.2. Within clinical notes or as a stand-alone document. The practice of creating,

importing, or uploading scanned documents and images into AHLTA (not directly

imbedded within a patient encounter note), is not authorized without approval from

AFMAN41-210 10 SEPTEMBER 2019 105

AFMSA/SG3S. Managing the capability to create, import, or upload, stand-alone

scanned documents should be accomplished through HAIMS application.

5.4.9.7.3. Alternative methods to capture consults and referral results. AHLTA is not

to be used for volume storage of TRICARE network consultation report or referral

results storage without approval from AFMSA/SG3S. Identified below is an optional

method that allows temporary data collection, storage, authorized user viewing, and

data sharing of electronic copies of consultation reports and referral results received

from civilian medical providers, is.

5.4.9.7.3.1. MTFs are authorized to use a local, secure, shared computer server or

data storage device, to temporarily store consultation reports and referral results

received from civilian medical providers and specialists.

5.4.9.7.3.2. No later than 30 days following the date they create the electronic file,

staff must destroy the contents the file. Those contents include reports or referral

results received, scanned and imported into HAIMS from external MTF providers.

This rule assumes AFMSA/SG3S did not authorize an exception that allows

importing and/or uploading reports or results into HAIMS. (T-3).

5.4.9.7.3.3. There is no limitation (unless prescribed locally) to specific file size or

type (in the MTF shared computer server).

5.4.9.7.3.4. The MTF will create specific processes and business rules to a) ensure

the referring provider has access to the temporary electronically stored consultation

report or referral results and is aware that those electronic document(s), file(s), or

image(s), will only be available for viewing 30 days following the creation of the

electronic copy, and b) processes are in place to ensure the original consultation

report or referral result(s) is scanned into HAIMS. (T-3).

5.4.9.7.3.5. The official government e-mail transfer of consultation reports and

referral results is authorized as long as the message(s) is digitally signed and

encrypted. Access to shared MTF computer folders and files, containing PHI, must

be limited to users who can demonstrate a verifiable need for access. (T-0). Shared

computer folders and files must offer limited user access and password protection.

(T-0). Once a data-at-rest solution is deployed, PHI on shared drives must be

encrypted in accordance with security standards. (T-0).

5.4.9.8. Filing, Scanning and Uploading New Documents into HAIMS. All specialty care

and urgent primary care results, Emergency Room (ER) notes, discharge summary reports,

laboratory results, and radiology reports generated by providers and health care

organizations external to the MTF shall be scanned and imported into HAIMS within three

working days from receipt of results. (T-0). Referring providers/Primary Care Managers

will be notified of the new results/report via telephone consult or locally established

protocol. (T-0). Providers will have three business days from the date of receipt to review

the results. (T-0). Tips on importing/scanning and standard naming conventions can be

found in "The Management of Artifacts Scanned into HAIMS” located in Medical

Records/HAIMS folder on the AFMOA Health Benefits Kx page at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx. If a particular

type of paper document was regularly reviewed and signed (by hand) by a provider and

106 AFMAN41-210 10 SEPTEMBER 2019

filed into the paper record, the same document must still be signed (by hand) before

scanning into HAIMS. (T-2). See 5.4.7 and 5.7.1 for additional instructions on printing.

5.4.9.9. Scanning Entire Paper Health Records for Importing or Uploading into HAIMS

or other Secure Database.

5.4.9.9.1. The practice of scanning entire original paper health records for permanent

storage, importing, or uploading into HAIMS or similar DoD approved document

management system is unauthorized.

5.4.9.9.2. The only exception to bulk scanning is when the MTF is processing records

for service members on active Presidential Support Program or Personnel Reliability

Assurance Program status and the mission needs require rapid electronic access to the

service treatment record. The MTF is then authorized to bulk scan the record into

HAIMS and mail the hard copy in accordance with standard procedures.

5.4.9.9.3. In support of the Personnel Reliability Assurance Program Administrative

Qualification Central Cell process, all paper health treatment records will be requested

from the losing MTF. (T-3). Paper medical and dental records must be scanned into

HAIMS within seven calendar days. (T-3).

5.4.9.9.4. Refer to Attachment 5: PERSONNEL RELIABILITY ASSURANCE

PROGRAM ADMIN CERT HAIMS SCAN GUIDE, also located at:

https://kx2.afms.mil/kj/kx2/AFMOAHealthBenefits/Documents/Forms/ShowFol

ders.aspx?RootFolder=%2Fkj%2Fkx2%2FAFMOAHealthBenefits%2FDocume

nts%2FMedical%20Records%2FHAIMS&FolderCTID=0x0120000459EFB11C

132E479D3C03001C859239&View=%7BDB7164E0%2DEF02%2D4CE4%2DA

D97%2DF6B6ED3D1D7B%7D.

5.4.9.10. Scanning in Lieu of Paper Copies. The practice of scanning original health

records in lieu of copying (for MTFs that offer this option) is authorized, as long as:

5.4.9.10.1. Digital or electronic memory, compact or read-writable discs or storage

media are marked with the following statement, “This electronic storage media may

contain information covered under the Privacy Act, and/or HIPAA and its various

implementing regulations and must be protected in accordance with those provisions.”

(T-0).

5.4.9.10.2. Scanned documents, files, and images are not stored on any local computer

or MTF computer hard drive permanently. Scanned images and documents must be

deleted from all computer, copier, and scanner hard drives, or the computer drives or

memory devices within these machines. (T-0).

5.4.9.10.3. Digital or electronic memory, compact or read-writable discs or storage

media are not included with paper health records when forwarded to the National

Personnel Records Center or to the VA Records Management Center via approved Air

Force health records disposition intermediary.

5.4.9.11. Electronic signatures on forms and documents. Handwritten (“wet”) signatures

and initials are not required on printouts of electronic forms and documents created by the

following systems: CHCS, AHLTA, Armed Forces Health Longitudinal Technology

AFMAN41-210 10 SEPTEMBER 2019 107

Application –Theater (AHLTA-T), Essentris, and TRICARE Online. Electronic signatures

and initials in these systems are equivalent to full handwritten signatures and initials.

5.4.9.12. Retrieving Outpatient Medical Records by Exception. The MTF commander or

director, with the recommendations from the Executive Committee of the Medical Staff

and Health Records Committee may stop or suspend the practice of routinely retrieving

paper outpatient medical or dental treatment records for provider use. It should be done

only after careful consideration and on the recommendations of the Executive Committee

of the Medical Staff and Health Records Committee. Only after addressing the following

minimum questions should a requesting work center, clinic, specialty group, or Family

Health Element team submit a request for retrieval and delivery of paper records to the

Executive Committee of the Medical Staff function.

5.4.9.12.1. Have procedures been developed to validate the beneficiary’s

acknowledgement of the MHS Notice of Privacy Practices? See AFI 41-200 paragraph

3.2 for additional information and requirements.

5.4.9.12.2. If a provider needs a paper record on a specific patient during treatment,

how will the clinic ensure the patient’s health record can be quickly obtained and

delivered to the requesting provider?

5.4.9.12.3. How will the transition from the traditional health record pull all to pull by

exception MTF business rule affect the requesting work center’s record availability

rate?

5.4.9.12.4. With recommendation from the Health Records Management Committee,

medical record retrieval variations may exist within a MTF that require specific clinics

to retrieve/receive the paper outpatient or dental treatment record in addition to

accessing AHLTA. This requirement should be reviewed annually (at a minimum) in

order to ensure that resources required to manage records are used to the best advantage

of overall operations.

5.4.9.13. Historic scanning by exception. If a provider identifies any document from the

patient's paper medical or dental record the document must be uploaded into the electronic

health record. (T-3). Following scanning, the original source document, file, or image must

be re-filed into the paper health record. (T-3). Once an item is uploaded into HAIMS, the

provider should determine whether the data is specific to an episode of care. If it is, the

item should be uploaded to the current patient encounter note without delaying the coding

process. The provider should also determine if the item should be uploaded as an

independent, stand-alone document.

5.4.10. HAIMS. HAIMS is a MHS strategic project that enhances medical informatics through

seamless integration of medical digital images into the electronic health record. The objective

of HAIMS is to give healthcare providers global awareness and access to essential health

artifacts and images throughout the continuum of care from Theater to the Sustaining Base to

the VA. HAIMS provides a single enterprise-wide image sharing capability for all types of

artifacts and images, including radiographs, photographs, wave forms, audio files, video files

and scanned documents.

5.4.10.1. Using HAIMS in the MTF. HAIMS is required to be used at all MTFs.

108 AFMAN41-210 10 SEPTEMBER 2019

5.4.10.2. HAIMS Administration. The MTF (outpatient records, referral management

centers, clinical departments, etc.), must use HAIMS exclusively to scan loose paperwork.

(T-3).

5.4.10.2.1. MTF Staff will cease filing loose paperwork in the hard-copy medical

record and instead scan/upload them into HAIMS. (T-3).

5.4.10.2.2. Once a loose document has been scanned, validated and uploaded into

HAIMS, the document shall be destroyed. (T-3).

5.4.10.2.3. Lackland Air Force Base, Maxwell Air Force Base, and United States Air

Force Academy will bulk scan entry paperwork. New paper records will not be created.

Members will not hand-carry medical records. (T-3).

5.4.10.2.4. New paper records will not be created for new dependents. (T-3).

5.4.10.3. HAIMS Training. MTF clinical systems trainers and super users are responsible

for training any users.

5.4.10.4. HAIMS Guidance. Tips on how to use HAIMS can be located on the Kx at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

5.4.10.4.1. HAIMS provides functionality that can be used to support the clinical

practice of medicine by making artifacts and images that are not already part of the

electronic health record accessible to providers.

5.4.10.4.2. Business Process Standardization. The requirement of appending artifacts

and images, by copying and pasting Clear and Legible Reports into AHLTA clinical

notes, is no longer in effect at MTFs due to the full implementation of HAIMS. The

standardized business process will now include placing these items into HAIMS. In

multi-service market areas, there must be close coordination between the Services

regarding this policy so that all the providers in those market areas will be able to access

the Clear and Legible Reports for individual patients. (T-3).

5.4.10.4.3. Artifacts and Images scanned into HAIMS are called assets. These assets

are identified by a process known as metadata tagging. Metadata must be entered

before an asset is saved in HAIMS. (T-3). In The HAIMS Clinical User Guide Table

1, there is a brief explanation of nearly 20 data entry fields. (T-2).

5.4.10.4.3.1. Patient Name: Auto-populates when the patient is selected in the

search function. Provides Patient Name, Social security number, Date of Birth,

Gender, and family member prefix/sponsor social security number. Search

function is similar to that currently employed with AHLTA.

5.4.10.4.3.2. Author Name: Free text. The author is considered the person

responsible for the original artifact (e.g. ordering provider or network provider).

Enter the full name of the author of the asset in “last name, first name” format.

5.4.10.4.3.3. Document Type: (Dropdown Menu). Click on the down arrow,

scroll down to and highlight the appropriate document type (e.g. Encounter Note,

Consultation) and enter.

5.4.10.4.4. In addition to the above three required metadata tags, HAIMS users will

utilize the following fields as much as possible within the constraints of local resources:

AFMAN41-210 10 SEPTEMBER 2019 109

5.4.10.4.4.1. Mark as Sensitive: Click on Box. Mark the document as “Sensitive”

to restrict access to it. When an asset is restricted, unauthorized users will not have

access to the document. All authorized users have access after acknowledging they

will be viewing sensitive data and will be subject to auditing. If in doubt whether

a document would be marked sensitive, HAIMS users will consult with the provider

or the mental health clinic to determine sensitive information.

5.4.10.4.4.2. MHS Form Number: Auto-Populate Field. Type a few characters

contained in the form number (e.g. 600). Highlight the proper form number (e.g.

SF 600, Chronological Record of Medical Care) and enter. Use this field when

there is a known form number.

5.4.10.4.4.3. Procedure or Service: Auto-Populate Field. Type a few characters

contained in the procedure or service code number. Highlight the proper service

(e.g. Ultrasound) or code number (e.g. 335.20) and enter.

5.4.10.4.4.4. Installation/Facility: Auto-Populate Field. Enter the first letter(s) of

the installation/facility. A dropdown list will appear. Select the appropriate

installation/facility and enter.

5.4.10.4.4.5. Facility Name: Free Text Field. If the asset was received from a

place not listed in the “Installation/Facility” field, enter the name of the

organization where the asset originated.

5.4.10.4.4.6. Clinic: Dropdown Menu. Click on the down arrow, scroll down to

and highlight the proper clinic type (e.g. Cardiology) and enter.

5.4.10.4.4.7. Specialty: Auto-complete field. Type a few characters contained in

the specialty name (e.g. obstet). Highlight the proper service (e.g. Obstetrics) and

enter.

5.4.10.4.5. Enclosures. There are 8 enclosures found within the clinical use of HAIMS

Guidance. Each enclosure provides guidance for acquiring assets and using assets in

the HAIMS embedded mode within AHLTA. The enclosures are listed below and

examples can be found on the Kx at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

5.4.10.4.5.1. ACQUIRING ASSETS

5.4.10.4.5.2. SCANNING ARTIFACTS

5.4.10.4.5.3. ENTERING HAIMS METADATA

5.4.10.4.5.4. ACCESSING HAIMS VIA “EMBEDDED MODE”

5.4.10.4.5.5. ASSOCIATING ASSET TO AHLTA CURRENT ENCOUNTER

5.4.10.4.5.6. ASSOCIATING ASSET TO AHLTA PREVIOUS ENCOUNTER

5.4.10.4.5.7. ASSOCIATING ASSET TO AHLTA PROBLEM

5.4.10.4.5.8. ASSOCIATION REMOVAL

5.4.10.4.6. Guidance for Making the Service Treatment Record Available for Access

by the VA

110 AFMAN41-210 10 SEPTEMBER 2019

5.4.10.4.6.1. Air Force Service Treatment Record Processing Center: The AFMS

has opted to centralize the Service Treatment Record digitization, for

retiring/separating members, into HAIMS for access by the VA. The Service

Treatment Record disposition process can be found in this manual in paragraph 5.7.

5.4.10.4.6.2. The home MTF/Dental Treatment Facility is responsible for securing

the service member’s paper Service Treatment Record, collecting all unfiled, loose

and late flowing documents and artifacts at the MTF and filing them properly in the

Service Treatment Record. This does not include electronic encounter information

maintained in AHLTA. Any loose and late flowing documents will be scanned and

uploaded into HAIMS by the MTF.

5.5. Electronically-Generated Forms.

5.5.1. Use only the Air Force-approved forms package. Word processing packages are

directly forbidden because there is no method of locking the form so that it cannot be changed

by the user. See AFI 33-360. Most Air Force, Standard Forms (SF) and Optional Forms (OFs)

can be obtained from the Air Force e-Publishing website at: http://www.e-publishing.af.mil.

5.5.2. The only exception to the rule in 5.5.1 is permission to use the forms for which

AFMOA/SGAT has identified standard data elements. For these forms, the standard elements

are required but mirror imaging of the paper form is no longer required. (T-1). Additional data

elements that would change the meaning of the form cannot be added. Standard patient

information is required on these forms.

5.5.3. Include the following patient information blocks on both inpatient and outpatient forms:

Name (last, first, middle), patient family member prefix/last four digits of the sponsor’s social

security number, DoD Identification Number, Sex, Date of Birth, Rank/Grade,

Department/Service Where Records Maintained, and Relationship to Sponsor. Under Sponsor

Information, include Name (last, first, middle) and last four digits of the Sponsors Social

security number and/or DoD Identification Number. Under Facility Information, include

Name of MTF. Additionally, add blocks for Register Number and Ward Number on inpatient

forms.

5.5.4. To date, the forms for which standard data elements have been identified for the body

of the form are: SF 93, Report of Medical History, SF 505, Medical Record – History Parts 2

and 3, SF 506, Medical Record – Physical Examination, SF 509, Medical Record – Progress

Report, SF 526, Medical Record – Interstitial/Intercavitary Therapy, SF 551, Medical Record

– Serology, SF 558, Medical Record – Emergency Care and Treatment, SF 559, Medical

Record – Allergen Extract Prescription – New and Refill, SF 600, and OF 523B. Contact

AFMOA/SGAT for a list of the identified standard data elements for these and any subsequent

forms for which standard data elements have been identified.

5.5.5. OF 275, Medical Record Report, may be used in lieu of SFs, Air Force forms and DoD

forms, available at https://www.gsa.gov/forms-library/medical-record-report. OF 275, if

used, must indicate the form number and title of the form being replaced. (T-3). Information

entered on the form must include all of the same information as the form it represents. (T-2).

Scan and upload the OF 275 into the patient’s electronic health record. This form is not to be

used for the creation of local forms.

AFMAN41-210 10 SEPTEMBER 2019 111

5.5.6. If a MTF desires to create a local form in lieu of a form that already exists, a waiver

must be requested from AFMOA/SGAT. (T-1).

5.5.7. In an effort to reduce the unnecessary use of Social security numbers, DoD has begun

the use of alternative Personal Identifiers in place of the Social security number. The

alternative Personal Identifiers include the DoD Identification Number which uniquely

identifies individuals and the DoD Benefits Number that identifies individuals eligible to

receive DoD benefits such as commissary, exchange, and TRICARE benefits. The MHS, when

feasible, should limit the use and display of Social security numbers while migrating systems

and business processes to use the DoD Identification Number.

5.5.7.1. Local MTF forms must be reviewed for the necessity of Social security number

use. (T-3). MTFs are encouraged to use DoD Identification Numbers in place of Social

security numbers on local forms. To locate Social security numbers, MTFs may obtain the

Social security number from General Inquiry of Defense Enrollment Eligibility Reporting

System (DEERS) Web Application by cross matching the DoD Identification Number on

the Identification card or form with the DoD Identification Number in the system.

5.5.7.2. If the MTF determines the continued use of the Social security number on a local

form is necessary, the MTF must comply with the justification procedures set forth in AFI

33-332. (T-2).

5.6. Overprinting of Forms. An overprint is a form displaying identical entries in an

appropriately captioned area or fillable field existing on a form. Overprints do not change the

information collected on a form and are authorized in accordance with AFI 33-360. The specific

overprint must be a) approved by the local body responsible for the medical record review function,

b) recorded in the minutes of that body, and c) approved by the MTF commander or director. (T-

3). Follow instructions in AFI 33-360 concerning inclusion of the name of the organization

followed by “overprint” in the lower right margin of the form; for example, 579 Medical Group

(MDG) Overprint. The list of Air Force forms authorized for overprint follows:

5.6.1. AF Form 230, Request for Patient Transfer.

5.6.2. AF Form 250, Health Record Charge Out Request.

5.6.3. AF Form 560, Authorization and Treatment Statement.

5.6.4. AF Form 565, Record of Inpatient Treatment.

5.6.5. AF Form 570, Notification of Patient’s Medical Status.

5.6.6. AF Form 577, Patient’s Clearance Record.

5.6.7. AF Form 2700L, Health Record Year Grid.

5.6.8. AF Form 745, Sensitive Duties Program Record Identifier.

5.6.9. AF Form 1403, Roster of Seriously Ill/Very Seriously Ill.

5.6.10. AF Form 1942, Clinic Index.

5.6.11. AF Form 3066, Doctor’s Orders (multiple copy format).

5.6.12. AF Form 3066-1, Doctor’s Orders (cut sheet format).

112 AFMAN41-210 10 SEPTEMBER 2019

5.7. Service Treatment Record Disposition Instructions for Airman Retiring, Separating

and Transitioning to the RC. There are two categories of Health Records: The first category is

the Service Treatment Record - the outpatient medical record and dental treatment record for a

member of the United States Military. It is made up of the patient’s medical and dental encounters

incurred throughout the course of their military career. The Service Treatment Record begins upon

entry to AD (Military Entrance Processing Station/intake physical or commissioning physical) and

ends upon discharge, retirement, separation or death (if death occurred while on AD). The second

category is the Non-Service Treatment Record - outpatient medical records for patients in all other

categories (dependents, civilians, foreign military, retirees, etc.). The following sections contain

guidance regarding the proper procedures to transfer, disposition, and retire all types of heath

records to the appropriate location. Dependent, Non-NATO Foreign military, and Retiree Non-

Service Treatment Records are retired to the National Personnel Records Center using the Medical

Record Tracking application in CHCS. Federal Civilian Employee Non-Service Treatment

Records are provided to the local Civilian Personnel Office or retired to National Personnel

Records Center.

5.7.1. The Service Treatment Record on-time submission goals to meet the Under Secretary

of Defense Personnel and Readiness expectations are 95% on-time submission of Active

Component Service Treatment Records and 75% on-time submission of RC Service Treatment

Records.

5.7.1.1. The Service Treatment Record process mandated that all AD Air Force MTFs and

ARCs begin mailing Service Treatment Records for retiring and separating Airmen (with

a separation or retirement date effective 1 January 2009 and thereafter) to the Air Force

Service Treatment Record Processing Center instead of forwarding records to the Air Force

Personnel Center.

5.7.1.2. Service Treatment Records shall be sent to the Air Force Service Treatment

Record Processing Center at 3370 Nacogdoches Rd, Suite 116, San Antonio, TX 78217.

(T-1). The cell will continue to receive bulk shipments of paper Service Treatment Records

for retiring and separating Air Force Service Members. Upon receipt, the cell will digitize

the paper records into HAIMS. (T-1). The original paper Service Treatment Record will

then be dispositioned according to DoD and National Archives and Records Administration

guidance.

5.7.1.3. Total Force Applicability: This Service Treatment Record disposition policy

applies equally to the AD MTFs and the RCs. Although the language that follows in this

paragraph specifically mentions MTF responsibilities and expectations, the guidance also

applies to Air Force Reserve (AFR), Air National Guard (ANG) medical units, and

organizations responsible for the day-to-day maintenance and storage of ARC Service

Treatment Records. Air Force Service Treatment Record Processing Center is the only Air

Force agency authorized to forward AD and RC Service Treatment Records to the VA.

MTFs and RCs are not authorized to mail records directly to the VA. (T-0). Reference

DoDI 6040.45.

5.7.1.4. All MTF and Dental Treatment Facility records management personnel will apply

the following directions to their Service Treatment Record disposition plan. (T-0). MTF

records managers and supervisors must work closely with their Dental Treatment Facility

counterparts and local Military Personnel Section, Military Personnel Element, Military

AFMAN41-210 10 SEPTEMBER 2019 113

Personnel Squadron or Force Support Squadron officials to make this transition as smooth

as possible. (T-0). Reference DoDI 6040.45.

5.7.1.5. Incorporate the Service Treatment Record disposition instructions into all

standard MTF, Dental Treatment Facility, and RC Service Treatment Record disposition

instructions for retiring, separating, discharging, and transitioning members. Reference

DoDI 6040.45.

5.7.2. AFPC Retirement/Separation Notification Roster (also known as LOSS Roster).

5.7.2.1. In order to streamline the process and standardize LOSS Rosters acquisition

procedures, a Medical Records Management SharePoint website was created so MTF,

Dental Treatment Facility, and ARC records managers could easily obtain this time

sensitive information.

5.7.2.2. Personnel LOSS rosters include a listing of all projected retiring, separating,

transitioning, and discharging Air Force service members (AD and ARC), to include those

assigned to GSU. The rosters also identify Airmen who retired or separated in previous

months which the Air Force Service Treatment Record Processing Center has not received

a complete Service Treatment Record. The column with a header of “Record Required”

on each roster indicates the original component(s) which have still not been received by

the Air Force Service Treatment Record Processing Center. Note: These records will

continue to remain on the roster until the Air Force Service Treatment Record Processing

Center receives the records or a Non-Availability Letter.

5.7.2.3. Identified MTF, Dental Treatment Facility, and ARC personnel must obtain the

LOSS roster from the Medical Records Management SharePoint each month. (T-1). The

local Military Personnel Section will continue to provide support in the case of short-notice

changes and any other questions which might arise. As the LOSS rosters contain

Personally Identifiable Information, and the SharePoint site contains all rosters for all

facilities, access to the page is restricted to only those individuals who require access to

perform Service Treatment Record disposition duties.

5.7.2.4. Each MTF or ARC is authorized one primary and four alternate points of contact,

for a total of five (5). ARCs are authorized an additional two members in order to identify

the Senior Air Reserve Technician and the Medical Administrative Officer. It is

recommended that the primary point of contact should be the individual with direct

oversight of the records process (NCOIC, in most cases). (T-1). Alternates should be a

dental representative, flight commander or superintendent. Each member must be

designated in writing by the unit commander. (T-1). An example of an appointment letter

is available on the Medical Records Management SharePoint and the AFMOA Health

Benefits Kx page. As the rosters are in Excel format, they can be downloaded, saved and

distributed locally as the facility deems necessary. However, given the information on the

spreadsheet, access must be limited to only those with a need to know. (T-0). E-mail

messages containing Personally Identifiable Information must be digitally signed and

encrypted. (T-0).

5.7.2.4.1. The appointment letter must include the reason for request and must be

signed by the squadron commander. (T-1). Appointment letters can be

updated/resubmitted at any time; letters will be updated at least annually. (T-1).

114 AFMAN41-210 10 SEPTEMBER 2019

5.7.2.4.2. Address appointment letters to AFMOA/SGAT and scan/e-mail the

document to usaf.jbsa.afmoa.mbx.str-processing-center@mail.mil.

5.7.2.4.3. Once the appointment letter has been submitted and approved, the Air Force

Service Treatment Record Processing Center Managers will grant access to the Medical

Records Management SharePoint. (T-1).

5.7.2.5. At MTFs with decentralized medical record filing rooms, the TRICARE

Operations and Patient Administration office is responsible for distributing the LOSS

rosters to each record room.

5.7.2.6. Once the appointment letter has been submitted and approved, the Air Force

Service Treatment Record Processing Center Managers will grant access to the Medical

Records Management SharePoint. (T-1).

5.7.2.7. The LOSS rosters are located in the main folder "Medical Record Rosters”, and

then in the sub-folder “Medical Record Departure Rosters” for the applicable month. The

folders correspond with the month the roster was run.

5.7.2.8. Each roster on the SharePoint is listed separately by Personnel Accounting

Symbol (PAS) Code. A number of installations have RCs assigned/co-located with the

AD MTF; therefore, these bases will appear to be listed more than once. The first 2 digits

of the PAS Codes determine the applicability of the roster. Generally, AD PAS Codes are

two ALPHA characters, whereas RC PAS Codes are identified by an ALPHA Numeric

code. For instance, McConnell Air Force Base could appear three times: McConnell

(MK); McConnell (D6); and McConnell (R2). The AD MTF roster is identified by (MK),

the Guard roster is identified by (D6) and the Reserve unit is identified by (R2).

5.7.2.9. Some larger MTFs have more than one Military Personnel Section providing

services at their installation; therefore, MTFs and RCs also need to know the two-digit PAS

Code for each of those Military Personnel Section/GSU for which they provide

care/maintain records. A memorandum of understanding/memorandum of agreement is

required for each MTF or RC if co-located with another MTF/RC (regardless of Service

affiliation) to ensure correct Records Management procedures/policies are followed and

addressed.

5.7.2.10. PAS codes can be obtained from the AFPC secure web site at:

https://mypers.af.mil/app/login/redirect/home. After accessing the site, click “OK,”

then “PAS CODES.” The PAS codes are also located on the Medical Records Management

SharePoint in the Departure Rosters folder.

5.7.2.11. For questions regarding which roster to obtain, contact the local Force Support

Squadron, or the Reserve, Guard, or AFMOA Health Benefits regional representative for

assistance.

5.7.2.12. Facilities have a window of opportunity when records should be mailed to arrive

at the Air Force Service Treatment Record Processing Center. The LOSS roster contains

two columns for shipment dates for the Service Treatment Record to arrive at the Air Force

Service Treatment Record Processing Center, “no earlier than” and is due “no later than.”

The no earlier than date is the member’s date of retirement/separation; the no later than

date is 30 days after the member’s date of retirement/separation. Medical records

AFMAN41-210 10 SEPTEMBER 2019 115

personnel at all Air Force MTFs and ARCs must mail a retiring/separating member’s

Service Treatment Record to arrive at the Air Force Service Treatment Record Processing

Center no earlier than the Date of Retirement/Date of Separation and no later than 30 days

past the Date of Retirement/Date of Separation. (T-0). Reference DoDI 6040.45.

5.7.2.13. GSU: Service Treatment Records for retiring and separating Air Force service

members assigned to remote units or GSU must be maintained at the MTF serviced by the

Military Personnel Section to which the member is assigned. (T-3). If the Airman is

enrolled to a TRICARE network Primary Care Manager, civilian medical documents are

maintained at the network Primary Care Manager Office. If the individual appears on the

MTFs/Reserve Medical Units roster, that specific MTF/RC is responsible and will be held

accountable for its disposition. (T-1).

5.7.2.14. Outside Continental United States (OCONUS) Based Member

Retiring/Separating: Based on AFPC guidance, retiring/separating members assigned

OCONUS are directly retired/separated by the OCONUS Military Personnel Section;

members are no longer allowed to receive a PCS to CONUS for retirement/separation

processing. However, even if a retiring/separating member based at an OCONUS MTF

returns stateside just for the purpose of retiring/separating, the OCONUS MTF Service

Treatment Record LOSS roster normally reflects the member as retiring/separating. It is

the OCONUS MTF’s responsibility to ensure the Service Treatment Record is

appropriately dispositioned to the Air Force Service Treatment Record Processing Center.

5.7.2.15. ARC LOSS Rosters will be assessed and downloaded from the AFPC Medical

Records Management SharePoint. (T-1).

5.7.3. Retirement/Separation/Transition Orders.

5.7.3.1. AD Personnel Responsibilities:

5.7.3.1.1. Retiring/Separating Airmen are required to report to the central MTF health

records customer service location and the installation Dental Treatment Facility with

their retirement orders no later than five days prior to the member’s final out-processing

appointment. The member is required to provide four copies of their retirement orders

(or, in the case of separations, the AF Form 100, Request and Authorization for

Separation); two for the MTF and two for the Dental Treatment Facility records

departments.

5.7.3.1.2. Airmen transitioning from the AD to the RC are required to report to the

central MTF health records customer service location with their service transition

order, PCS order, or AD separation order no later than five days prior to the member’s

final out-processing appointment. The member is required to provide two copies of the

service transition order, PCS order, or AD separation order. (Specific rules regarding

the disposition or the transfer of Service Treatment Records for Airmen transitioning

from the Active to the RC are identified in paragraph 5.7.5.11.)

5.7.3.2. MTF/Dental Treatment Facility Responsibilities:

5.7.3.2.1. The MTF and Dental Treatment Facility will each place one copy of the

orders in the member’s outpatient medical and dental treatment records. (T-1). In the

outpatient medical record, the member’s orders will be placed in Section II. (T-1). In

116 AFMAN41-210 10 SEPTEMBER 2019

the dental treatment record, the member’s orders will be placed on the inside right-side

folder section. (T-1).

5.7.3.2.2. The second copy of the orders will be placed into a plastic AF Form 885-

887 series, Medical Record Charge-Out Guide and filed in place of the record. (T-0).

It is also recommended to include a reference to where the record is located (transitory

file) until the record is mailed. Reference DoDI 6040.45.

5.7.3.2.3. Missing Orders. MTFs and RCs should not delay processing Service

Treatment Records for transfer to the Air Force Service Treatment Record Processing

Center due to missing service member orders. If, after contacting the Military

Personnel Section or accessing the Virtual Military Personnel Section, a copy of the

orders cannot be obtained, the Service Treatment Record may be sent without the

orders. MTFs and RCs must verify or check with the military personnel section prior

to shipment to ensure the Airman did not re-enlist or extend the enlistment. (T-1).

5.7.3.2.4. AD Virtual Military Personnel Section Checklist Confirmation. Outpatient

medical and dental records managers and Force Health Management officials will work

together to ensure each outbound Airmen has fulfilled all of the MTF out-processing

responsibilities. (T-0). Reference DoDI 6040.45.

5.7.3.2.5. Checklist Operation. Multiple (at least two) staff members assigned to MTF

and Dental Treatment Facility records departments will be granted Virtual Military

Personnel Section Checklist access to ensure each departing service member is

informed of the requirement to provide the MTF and Dental Treatment Facility with

copies of the member’s orders at the time of MTF/Dental Treatment Facility out-

processing. (T-1). Access will also allow MTF records managers to obtain and print

individual retirement/separation orders when necessary. Once added to the process or

granted access to the Virtual Military Personnel Section system, records managers can

forecast the timeframe when separating and/or retiring Airmen will visit the MTF and

Dental Treatment Facility to out-process. (T-1). MTF and Dental Treatment Facility

records managers may also be able to add special notes to the Virtual out-processing

checklists to inform out-processing Airmen to obtain a copy of their Service Treatment

Record no earlier than 179 calendar days and no later than 30 days prior to the date of

their final separation or retirement date.

5.7.3.3. AFR Personnel. Each month, the servicing Reserve Military Personnel Section

will provide the servicing RMU a copy of the retirement/discharge/transition orders. (T-

1). Alternatively, the AF Form 1288, Application for Ready Reserve Assignment may be

provided. Orders are provided to the RMU for assigned Airmen serviced by the Military

Personnel Section, including GSU personnel, with a 60-day projected retirement,

discharge, or transition to inactive status date.

5.7.3.4. ANG Personnel. Guard members receive their retirement/discharge orders from

the Retirements/Separations department of the Military Personnel Section located at their

ANG Wing. These retirement/separation orders should be received at the monthly Unit

Training Assembly immediately preceding the final service obligation date.

5.7.4. Making Copies of Outpatient Medical and Dental Records.

5.7.4.1. For the AD Service Member:

AFMAN41-210 10 SEPTEMBER 2019 117

5.7.4.1.1. Separating and retiring Airmen may request one complete copy of their

Service Treatment Record no earlier than 179 calendar days and no later than 30

calendar days prior to the date of their final out-processing appointment. Only one

copy free of charge is authorized. The goal is to have one complete Service Treatment

Record copy ready for the separating or retiring Airman by the time of his final

MTF/Dental Treatment Facility out-processing appointment. The copy can be

provided as a hard-copy record or in electronic or digital media format, whichever the

member requests. Note: This copy is for the member’s personal use, not for the VA

as the VA requires the record in electronic format. Do not scan the medical or dental

record into HAIMS, as the Air Force Service Treatment Record Processing Center is

the only entity that has the authority to place complete records into HAIMS. Ensure

patient understands they are only authorized one complete copy free of charge. They

will not receive another copy (free of charge) if they give their copy to the VA.

5.7.4.1.2. Copy requests should be fulfilled no later than 30 calendar days from the

date of copy request receipt. Records managers must use all available resources within

their means to ensure separating and retiring Airmen understand the importance of

submitting their Service Treatment Record copy requests as early as possible. (T-3).

The volume of electronic patient encounter documents generated from MTF or Dental

Treatment Facility visits that fall within the 30-day cut-off copy request date through

the Airman’s MTF/Dental Treatment Facility out-processing date are usually not that

significant. These few documents should be reasonably easy to identify and print from

AHLTA or CHCS, on the spot, or copy from the paper outpatient medical or dental

records and added to the copy package or provided to the member at the time of out-

processing.

5.7.4.1.3. MTF records managers are expected to notify the Transition Assistance

Program (TAP) of the member’s right to one free copy of their record upon separation

or retirement. MTF records personnel will ensure local installation Transition

Assistance Program officials are aware that each AD Airman enrolled in Transition

Assistance Program class may receive a copy of their Service Treatment Record no

earlier than 179 calendar days, but not later than 30 calendar days prior to their final

retirement or separation date.

5.7.4.2. For the ARC Service Member:

5.7.4.2.1. Separating and discharging ARC service members may request one

complete copy of their Service Treatment Record no earlier than 179 calendar days and

no later than 90 calendar days prior to the date of their final out-processing

appointment. Only one free copy is authorized. The goal is to have one complete

Service Treatment Record copy ready for the retiring or discharging Airman by the

completion of the final medical unit out-processing appointment.

5.7.4.2.2. Copy requests from MTFs should be fulfilled no later than 30 days from the

date of copy request receipt. Requests for copies from ARCs will be fulfilled. (T-1).

ARCs are not regularly staffed as well as full-time AD MTFs. Opportunities to make

copies for retiring or discharging members may be diminished, sometimes limited to

only drill weekends. Ninety calendar days is a reasonable period of time to complete

the copy request. Records managers must use all available resources within their means

118 AFMAN41-210 10 SEPTEMBER 2019

to ensure ARC retiring and discharging Airmen understand to submit their Service

Treatment Record copy requests as early as possible. (T-3). The volume of electronic

patient encounter documents generated from MTF, Dental Treatment Facility or RC

visits that fall within the period from the 90-day cut-off copy request date through the

Airman’s MTF, Dental Treatment Facility or ARC out-processing date should not be

that significant. These few documents should be reasonably easy to identify and print

from AHLTA or CHCS on the spot, or copy from the paper outpatient medical or dental

records and added to the copy package or provided to the member at the time of out-

processing.

5.7.4.2.3. For those ARCs without AHLTA, CHCS, or HAIMS access, records

managers are required to contact the AD MTF to obtain copies of all AHLTA/CHCS

encounters, ancillary laboratory and radiology results. (T-1). Provide a copy of the

service member’s pharmacy prescription medication history only upon specific request.

5.7.4.2.4. Although the Transition Assistance Program may not be available for many

ARC Airmen, ARC unit commanders, first sergeants, personnel staff, and medics are

encouraged to inform retiring or discharging ARC Airmen of the necessity to obtain a

complete copy of their Service Treatment Record as soon as possible.

5.7.4.3. Service Treatment Record Composition.

5.7.4.3.1. The Service Treatment Record includes traditional paper outpatient medical

and dental documents stored in the outpatient medical and dental records as well as

ancillary laboratory and radiology reports stored and printed from CHCS, outpatient

patient encounter notes and any other PHI reports, data, or information stored and

printed from AHLTA. Copies of clinical narrative summaries and operation reports

from previous inpatient, ambulatory procedure visit, and/or Medical Evaluation Board

actions should already be filed in Part I or III of the member’s outpatient record.

However, MTF records managers or Release of Information staff will verify that any

narrative summaries and/or operation reports generated from past inpatient, ambulatory

procedure visit or Medical Evaluation Board actions completed at the same MTF

responsible for the Service Treatment Record disposition, are included in the paper

outpatient medical record. (T-1).

5.7.4.3.1.1. AHLTA Web Print. AHLTA Web Print is a feature in AHLTA that

allows a user to print or generate a PDF file of a patient’s entire electronic health

record, or specific sections thereof, with one command. The AHLTA Web Print

menu will appear as a link in the AHLTA folder tree. The user interface screen

permits configuration and setting of desired report options. These options allow

the user to customize the printed report by limiting the report to a specified date

range or clinical domains to be included in the report, and to even generate a mailing

page.

5.7.4.3.1.2. Given that AHLTA Web Print file comes complete with a Table of

Contents which specifies page numbers for each item, it is no longer logical to file

individual items in each applicable section of the record (i.e. SF600's in Section 2,

labs/rads in Section 4, etc.). As such, the entire printed copy of the electronic health

record should be kept together as one file, to reduce confusion on where an

encounter identified in the Table of Contents is located. In the event a patient’s

AFMAN41-210 10 SEPTEMBER 2019 119

entire electronic health record must be printed/filed, MTFs/RCs (utilizing AHLTA

Web Print) should file the AHLTA Web Print PDF as a complete packet in one of

the following ways (T-3):

5.7.4.3.1.2.1. If the patient's original paper record is small enough, the entire

packet can be filed as the top documents in Section 2.

5.7.4.3.1.2.2. If the patient's original paper record is too large, the AHLTA

Web Print packet should be placed in its own jacket (another volume), filed in

Section 2.

5.7.4.3.2. AHLTA Web Print and Service Treatment Record Disposition. The

availability of AHLTA Web Print in the AFMS has provided significant benefits to

reducing the workload associated with printing electronic health record documentation.

As such, patient encounter notes, printable clinical notes, radiology procedures, and

laboratory test results electronically stored in AHLTA are no longer required to be

printed and filed in the outpatient medical record prior to forwarding to the Air Force

Service Treatment Record Processing Center. The Service Treatment Record

Processing Center will utilize AHLTA Web Print to generate all AHLTA electronic

health record documents into the AHLTA Web Print PDF and upload it into HAIMS

during Service Treatment Record digitization, thereby making the complete Service

Treatment Record available to the VA in one process. (T-1).

5.7.4.3.3. AHLTA Web Print and Non-Service Treatment Record Retirement. Non-

Service Treatment Record, outpatient medical records for patients in all other

categories (dependents, civilians, foreign military, retirees, etc.), are retired to National

Personnel Records Center using e7m,8Treatment Record Retirement, is outlined in

detail in paragraph 5.7.12. Until necessary data communication links are permanently

established between both the MHS and National Personnel Records Center electronic

health record systems. MTF records personnel must continue to print and file (into the

patient’s paper record) all available ancillary, diagnostic or clinical information

electronically stored electronic health record prior to final records retirement

processing and shipment. (T-0). If MTF records personnel do not have access to

necessary AHLTA or CHCS systems to identify and print patient encounters, radiology

reports, and laboratory reports, then the patient’s Primary Care Manager support staff

is expected to complete this requirement and forward the documents to the MTF

outpatient medical and/or dental departments for inclusion into the Non-Service

Treatment Record.

5.7.4.4. To ensure reasonable continuity of care and or VA disability

evaluation/consideration, documents generated from civilian healthcare providers, stored

in any MTF health record, are included in the Service Treatment Record. Examples

include:

5.7.4.4.1. Reports and documents received from civilian referral healthcare providers.

5.7.4.4.2. Reports and documents from TRICARE Prime and TRICARE Prime

Remote civilian network providers. When a service member assigned to a remote unit

or GSU is enrolled to a TRICARE network Primary Care Manager, civilian documents

are owned and maintained at the network civilian Primary Care Manager office. At the

120 AFMAN41-210 10 SEPTEMBER 2019

time of the separating or retiring Airman’s MTF, Dental Treatment Facility or ARC

records department out-processing appointment, each Airman enrolled to a TRICARE

civilian Primary Care Manager should complete an authorization to obtain healthcare

information from the civilian Primary Care Manager and/or any civilian healthcare

provider. These documents should be forwarded to the MTF where the Service

Treatment Record is maintained so that Release of Information staff can make the

patient a copy, then include these civilian documents into the Service Treatment

Record. MTF records managers are expected to communicate this process to separating

and retiring Airmen attending Transition Assistance Program class so last minute

civilian Primary Care Manager requests do not delay Service Treatment Record

disposition.

5.7.4.5. Providing Copies for the Benefits Delivery at Discharge Program.

5.7.4.5.1. The Benefits Delivery at Discharge Program is a joint initiative between the

VA and the DoD. This program enables VA representatives to help transitioning

Airmen assemble and prepare their disability claim packages for VA disability

compensation and benefits review prior to their service separation or retirement. The

original Service Treatment Record is not provided to the Benefits Delivery at Discharge

office. Instead, the MTF will provide the member with a paper copy or electronic copy

(CD/DVD) of the Service Treatment Record at the member’s request. (T-1). Note:

this copy is counted as the member’s one complete copy free of charge.

5.7.4.5.2. Regardless of who maintains the records, if the individual appears on the

MTF/Reserve Medical Units roster, that specific MTF/ARC is responsible for

searching and sending the record or an acceptable Non-Availability Letter to the Air

Force Service Treatment Record Processing Center and will be held accountable for its

disposition.

5.7.4.5.3. Service Treatment Record records managers, as stewards of the Medical

Corps and appointed maintainers of the medical/dental records, have an obligation to

Veterans – to ensure their complete Service Treatment Record is ready and available

to the VA when the member chooses to file a claim. While a claim can be initiated

with a copy of the medical record, it is not official or complete without the original

records. Without the original record, the member’s claim will be left incomplete and

unfiled and the member will not receive their due compensation.

5.7.5. Collecting and Preparing Service Treatment Records for Shipment.

5.7.5.1. Once the LOSS rosters are obtained, retrieve the applicable outpatient medical

records and place them in a staging area separate from the main file located within a secure,

limited access room. File the Service Treatment Records in chronological order according

to the LOSS Roster shipment date. This will help ensure the Service Treatment Records

are mailed to arrive at the Air Force Service Treatment Record Processing Center by the

deadline. Service Treatment Records must be mailed no earlier than Date of

Separation/Date of Retirement and no later than 30 days after the member’s final date of

separation/retirement. (T-1).

5.7.5.2. No later than one business day after the Airman’s date of separation/retirement,

MTF and Dental Treatment Facility records personnel will ensure the dental treatment

AFMAN41-210 10 SEPTEMBER 2019 121

records for each separating and retiring Airman are forwarded to a central MTF location

where they will be bundled with the outpatient medical record and staged until ready for

mailing to the Air Force Service Treatment Record Processing Center. (T-1). Note: The

outpatient medical and dental records for each Airman must be bundled together before

shipping to the Air Force Service Treatment Record Processing Center. (T-0). Reference

DoDI 6040.45. Do not mail the outpatient and dental records separately. (T-0). Reference

DoDI 6040.45. Exception: Separate shipment may be necessary, for those medical or

dental records or other record volume that may be at another installation. Do not hold

medical or dental records after the member’s Date of Separation to include documentation

or encounters generated for any care they may receive after Date of Separation.

5.7.5.3. Missing Records: With the DoD-wide implementation of AHLTA, almost all

Service Members have patient medical encounters documented electronically. MTFs/RCs

must have and implement thorough in and out-processing procedures to ensure all records

for a patient are available as soon as possible. (T-0). Reference DoDI 6040.45.

5.7.5.3.1. Each Service has developed its own process to provide Service Treatment

Records to the VA. The VA provides metrics for each Service (similar to the Service

Treatment Record metrics) to Office of the Secretary of Defense (OSD), the White

House and Congress.

5.7.5.3.2. Each Service is held 100% accountable for missing records/record

components. Regardless of who maintains the records, if the individual appears on the

MTF/Reserve Medical Units roster, that specific MTF/ARC is responsible for

searching and sending the record or an acceptable Non-Availability Letter to the Air

Force Service Treatment Record Processing Center and will be held accountable for its

disposition. (T-1).

5.7.5.4. Non-Availability Letter, Verification Checklist, for Lost Original Paper Records:

5.7.5.4.1. If the original hardcopy dental or outpatient medical records cannot be

located send a Non-Availability Letter and completed Verification Checklist indicating

which original record is lost. If both hardcopy records cannot be located, include a

Non-Availability Letter and two completed verification checklists. An example is

available on the Medical Records Management SharePoint and the AFMOA Health

Benefits Kx page at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx. Note: If

both the original paper dental and original paper outpatient medical record(s) are lost,

include a Non-Availability Letter and two completed Verification Checklists.

5.7.5.4.1.1. If a Service Treatment Record cannot be located upon notification of a

member separating or retiring, the Verification Checklist and signed Non-

Availability Letter to declare unavailability must be completed. (T-0). These items

must arrive to the Air Force Service Treatment Record Processing Center no later

than the member’s Date of Separation/Date of Retirement plus 30 calendar days

(Date of Separation/Date of Retirement + 30). (T-0). Also, bundle these items with

all available parts of the Service Treatment Records. (T-2). Note: If the MTF

cannot find a full or partial Service Treatment Record but sends a compliant

package, the Air Force Service Treatment Record Processing Center will complete

due diligence for 10-12 days. If Service Treatment Record components are not

122 AFMAN41-210 10 SEPTEMBER 2019

located the Air Force Service Treatment Record Processing Center will certify all

available documents to the VA with AHLTA Web Print, prior to the Date of

Separation +45 deadline. Despite this certification by the Air Force Service

Treatment Record Processing Center, the MTF is still required to process a Non-

Availability Letter and complete due diligence, to include initiating a HIPAA

breach report.

5.7.5.4.1.2. MTFs will mail complete Service Treatment Records or any loose

documentation to the Air Force Service Treatment Record Processing Center no

later than date of Separation/Date of Retirement +30 days in order to allow the Air

Force Service Treatment Record Processing Center enough time to certify the

Service Treatment Record by Date of Separation/Date of Retirement +45 days.

5.7.5.4.1.2.1. The Air Force Service Treatment Record Processing Center will

provide the unit a list of records that were certified, after due diligence, without

MTF input. MTFs will complete HIPAA breaches, defined as the acquisition,

access, use, or disclosure of PHI in a manner not permitted under the HIPAA

Privacy Rule which compromises the privacy or security of the PHI for

incomplete Service Treatment Records. Refer to AFI 41-200.

5.7.5.4.1.2.2. MTFs will support the Air Force Service Treatment Record

Processing Center (respond to queries) as the Air Force Service Treatment

Record Processing Center completes due diligence during its research of

incomplete Service Treatment Records. (T-1).

5.7.5.4.1.2.3. MTFs will mail any Service Treatment Records that are found to

the Air Force Service Treatment Record Processing Center, even after the

Service Treatment Record has been certified. (T-1).

5.7.5.4.2. The commander of the MTF, group, or clinic responsible for the day-to-day

maintenance and storage of the lost record identified in the letter must wet or digitally

CAC sign the Non-Availability Letter. (T-1). Exception: The Medical Administrative

Officer is allowed to sign ANG letters and the Senior Air Reserve Technician is

allowed to sign AFR letters. The signature block must reflect the job title of the person

signing. (T-1). Signature delegation is not authorized. (T-1).

5.7.5.4.3. Air Force Members Empaneled to Sister-Service MTFs: Service Treatment

Records for AD service members are normally maintained at the MTF where the

member receives primary care, regardless of service affiliation. The health record

management officials at the Air Force MTF located nearest to the member’s Sister-

Service Primary Care Manager/MTF location must establish a local Service Treatment

Record Support Agreement (memorandum of understanding/memorandum of

agreement) (For an example of the memorandum, see AFMOA Health Benefits Kx

page at (https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx)

with the Sister-Service MTF. (T-1). Memorandum of understanding verbiage should

include both service processes. The agreement should identify how the Service

Treatment Records will be transferred from the Sister-Service MTF. How this is

accomplished is jointly decided by the MTFs, but acceptable methods include:

5.7.5.4.3.1. The Sister-Service MTF may mail the Service Treatment Record to the

AFMAN41-210 10 SEPTEMBER 2019 123

nearest Air Force MTF for subsequent mailing to the Air Force Service Treatment

Record Processing Center.

5.7.5.4.3.2. The Sister-Service MTF may forward the Service Treatment Record

directly to the Air Force Service Treatment Record Processing Center if they use

the instructions outlined in this document. Include a copy of the Service Treatment

Record disposition instructions with the agreement if this method is chosen.

5.7.5.4.4. There may be instances when the member is assigned to a GSU and the

responsible Air Force MTF is not the nearest MTF to the member’s Sister-Service

Primary Care Manager/MTF location. In these cases, see rules for managing GSU

records in the instructions that follow.

5.7.5.5. Non-Air Force Service Members Empaneled to Air Force MTFs:

5.7.5.5.1. Service Treatment Records for non-Air Force service members are normally

maintained at the Air Force MTF when the member is empaneled to the Air Force MTF.

Unless there is a local Service Treatment Record Support Agreement stating otherwise,

Service Treatment Records for Sister-Service members should be mailed to the

applicable address included in Attachment 11 of this AFMAN, with the appropriate

documentation (i.e. orders, Non-Availability Letter, etc.).

5.7.5.5.2. If a local Service Treatment Record Support Agreement is established with

another Service, the agreement must identify how the Service Treatment Record will

be transferred to the applicable Service. (T-1).

5.7.5.6. Personnel Assigned to GSU.

5.7.5.6.1. If the MTF identified on the LOSS Roster is not the MTF that maintains the

retiring/separating member’s Service Treatment Record, the LOSS-Roster-named

MTF must coordinate with the MTF where the record is regularly maintained in order

to ensure the Service Treatment Records are mailed to the Air Force Service Treatment

Record Processing Center. (T-1). (Note: Names and numbers of the points of contact

at each Air Force MTF and RC are located on the Medical Records Management

SharePoint).

5.7.5.6.2. Once contacted, the MTF maintaining the Service Treatment Record must

mail the Service Treatment Record to the Air Force Service Treatment Record

Processing Center in accordance with this guidance. (T-1).

5.7.5.7. Packaging and Shipping Service Treatment Records

5.7.5.7.1. Items included in Service Treatment Record Bundles:

5.7.5.7.1.1. Outpatient medical record or Non-Availability Letter, Verification

Checklist.

5.7.5.7.1.2. Dental record or Non-Availability Letter, Verification Checklist.

5.7.5.7.1.3. Include a copy of the retirement/separation or discharge order in each

record. In the outpatient medical record, the member’s orders will be placed in

Section II. (T-1). In the dental treatment record, the member’s orders will be placed

on the inside right-side folder section, on top of all other pages. (T-1).

124 AFMAN41-210 10 SEPTEMBER 2019

5.7.5.7.2. Include the following items in the shipment box; the LOSS roster as an

inventory sheet stapled to an AF Form 330, Records Transmittal/Request and the

records bundles. (T-1).

5.7.5.7.2.1. Print the LOSS roster inventory sheet with only the following columns

showing: Social security number, Name, Date of Separation, Medical Records

(Yes/No)/In Health Artifact and Image Management Solution, Dental Records

(Yes/No)/Never Created, Date Record Mailed, Remarks, and NCOIC Signature.

5.7.5.7.2.2. Place the records bundles in order of the listed records on the LOSS

roster. 5.7.5.7.2.3. Write "SEE ATTACHED ROSTER" in the “Name” block on

the AF Form 330 type and staple together with the roster (inventory sheet). (T-1).

5.7.5.7.2.3.1. The NCOIC or records department supervisor must sign the

roster stating they have quality checked the shipment. (T-1). Annotate the

mailing date and annotate any remarks relevant to shipping. (T-1).

5.7.5.7.2.4. Note: MTF records management personnel must keep a copy of the

AF Form 330 and LOSS roster permanently or until the Office of the Under

Secretary of Defense for Personnel and Readiness and the Services establish a

disposition rule for AD records. (T-0). Reference DoDI 6040.45. Place together

with the postage tracking/arrival confirmation notice in a central location within the

Outpatient Records department.

5.7.5.8. Shipment Containers.

5.7.5.8.1. Boxes - Records personnel are required to use standard white record

retirement boxes or other same-sized box, purchased specifically for shipping. (T-1).

The maximum weight per shipping box is 50 pounds. Do not bundle standard shipping

boxes within larger containers for shipment as the Air Force Service Treatment Record

Processing Center mailroom will not accept large or heavy packages or containers.

MTF records personnel are responsible for ensuring boxes are thoroughly and securely

packed, labeled, and taped for shipping so as to prevent inadvertent opening during

shipment and subsequent loss of Service Treatment Records or delays in arriving at

destination.

5.7.5.8.2. Envelopes – If the Service Treatment Record bundle will easily fit into an

envelope, one may be used. Envelopes must be tear resistant (i.e. fiber/cloth-like

construction, such as TYVEK), securely packed, labeled, and taped for shipping so as

to prevent inadvertent opening during shipment and subsequent loss of Service

Treatment Records or delays in arriving at destination. (T-1).

5.7.5.9. Shipping Service Treatment Records.

5.7.5.9.1. Service Treatment Records will be mailed to arrive at the Air Force Service

Treatment Record Processing Center no earlier than the member’s Date of

Retirement/Date of Separation and should arrive no later than 30 calendar days after

the member’s date of retirement/separation/discharge or transition to inactive status.

(T-0). Reference DoDI 6040.45. All OCONUS MTFs will use commercially available

global delivery services to mail the Service Treatment Record to arrive at the Air Force

Service Treatment Record Processing Center on the no-earlier-than date to prevent the

AFMAN41-210 10 SEPTEMBER 2019 125

Service Treatment Record from arriving late at Air Force Service Treatment Record

Processing Center.

5.7.5.9.2. Do not mail a member’s outpatient and dental records separately; they must

be mailed together as a bundle. (T-0). Reference DoDI 6040.45.

5.7.5.9.3. Service Treatment Record bundles of outpatient and dental records for more

than one individual may be combined into one shipment box provided the destination

is to the same location.

5.7.5.10. Preferred Mailing Method.

5.7.5.10.1. Forward Service Treatment Record boxes/envelopes to the Air Force

Service Treatment Record Processing Center using standard First Class United States

mail with immediate delivery confirmation/acknowledgment, certified mail, or other

commercially available option, e.g., FedEx, that offers package tracking and

delivery/arrival confirmation.

5.7.5.10.2. If standard first class United States Postal Service is used, package tracking

and delivery/arrival confirmation or shipment via Certified Mail is required. These

services are typically available via the Base Information Transfer System or the Base

Information Transfer Center (BITC) at each major installation.

5.7.5.10.3. Commercial priority mailing services are usually offered through the MTF

mailroom.

5.7.5.10.4. Records personnel must keep postage tracking/arrival confirmation notice

permanently or until the Office of the Under Secretary of Defense for Personnel and

Readiness and the Services establish a disposition rule for AD records. (T-0). Place

together with the Air Force Form 330 and LOSS roster in a central location within the

Outpatient Records department.

5.7.5.10.5. Use of standard First Class United States Postal Service mailing method

alone, without package tracking and immediate delivery

confirmation/acknowledgment or certified mail receipt, is prohibited. (T-1). Return

receipt confirmation must not be dependent upon the timeliness or willingness of the

destination MTF to complete a DD Form 2825, Internal Receipt, or other manual

delivery confirmation receipt option. (T-1).

5.7.5.11. For Airmen transitioning from AD to the RC, records personnel will forward the

AD component to the Air Force Service Treatment Record Processing Center. The AD

service period will be available electronically for the RCs.

5.7.5.12. Medical Record Tracking Transition in CHCS. Update the CHCS Medical

Record Tracking Function to annotate the record has been mailed to the Air Force Service

Treatment Record Processing Center. Health records personnel will TRANSFER the

record in the CHCS Medical Record Tracking menu to the appropriate location. (T-1).

5.7.5.13. Handling Clarification Queries from the Air Force Service Treatment Record

Processing Center. Queries for clarification on Service Treatment Records (e.g., requests

for missing documents/records) must receive immediate MTF/ARC record management

action. (T-2). The Air Force Service Treatment Record Processing Center only has a 15-

126 AFMAN41-210 10 SEPTEMBER 2019

day window from time of Service Treatment Record receipt to ensure it is digitized

appropriately in HAIMS.

5.7.5.13.1. Track Air Force Service Treatment Record Processing Center queries and

their outcome in a local database. The method is left up to the MTF/ARC and could

include an electronic spreadsheet, simple ledger, or other method.

5.7.5.13.2. MTF/Dental Treatment Facility/ARC records managers have only two (2)

duty days from receipt of the inquiry to investigate and provide a response. Delayed

responses will require immediate explanation to AFMOA/SGAT. (T-1).

5.7.5.13.3. The MTF/Dental Treatment Facility/ARC may be contacted by phone or e-

mail. MTF/Dental Treatment Facility/ARC records managers may contact officials at

the Air Force Service Treatment Record Processing Center via telephone or return e-

mail with the results of the inquiry, whether or not the record or missing item was found

and when it will be sent to the Air Force Service Treatment Record Processing Center.

Annotate the results in the computer spreadsheet.

5.7.6. Managing Loose and/or Late-Flowing Medical Documents Following Service

Treatment Record Shipment. Loose and/or late-flowing medical documents are those medical

or dental documents discovered in the MTF or Dental Treatment Facility after the Service

Treatment Record has already been mailed to the Air Force Service Treatment Record

Processing Center or the departing member’s gaining RC.

5.7.6.1. Loose and/or Late-Flowing Medical Documents must be digitized into HAIMS in

accordance with the HAIMS scanning policy. (T-0).

5.7.6.2. Loose paperwork may be digitized at any facility with HAIMS access.

5.7.7. Large Shipments of Pre 1 Jan 14 Medical and Dental Records/Loose Documents

Processing:

5.7.7.1. The following guidance applies only to records collected for Airmen who

separated/retired before 1 January 2014. Due to limited space and storage capabilities at

the Air Force Service Treatment Records Processing Center, shipments of Pre-January

2014 Service Treatment Records must be coordinated and approved prior to sending. (T-

1).

5.7.7.2. MTF records personnel are required to temporarily stage the outpatient and dental

records together in a central records storage location, separate from the main MTF file or

records room. (T-1). Ensure the following steps are taken:

5.7.7.2.1. If the information on hand is only loose documentation or less than 10 pages,

digitize it in HAIMS. Exception: If the service member is an Entry Level Separation,

the record may be less than 10 pages and should be mailed to the Air Force Service

Treatment Records Processing Center.

5.7.7.2.2. Complete an AF Form 330 along with an inventory list containing the

required data elements listed below. See examples located in patient administration

misc. document folder on the AFMOA Health Benefits Kx page at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

5.7.7.2.2.1. NAME (Last, First).

AFMAN41-210 10 SEPTEMBER 2019 127

5.7.7.2.2.2. SOCIAL SECURITY NUMBER.

5.7.7.2.2.3. MEDICAL RECORD (YES/NO).

5.7.7.2.2.4. DENTAL RECORD (YES/NO).

5.7.7.2.2.5. COMMENTS.

5.7.7.2.2.6. SIGNATURE BLOCK (Flight Commander, NCOIC, or Records

Department Supervisor).

5.7.7.3. Maintain the records in the central records storage location until directed by

AFMOA/SGAT to mail them to the Air Force Service Treatment Record Processing

Center. Do not mail these records until directed to do so by AFMOA. Large pre-

coordinated shipments of Service Treatment Records will be mailed to the Air Force

Service Treatment Record Processing Center at the following address: (T-1).

AF STR Processing Center

3370 Nacogdoches Road, Suite 116

San Antonio, TX 78217

5.7.8. AD and ARC records disposition rules are subject to frequent changes. For the latest

information, contact the Records Management Support Team, AFMOA/SGAT via e-mail at

usaf.jbsa.afmoa.mbx.str-processing-center@mail.mil.

5.7.9. Sequestered/Deceased Member’s Records. In the event a Service Treatment Record is

sequestered for legal reasons or has already been provided to the installation Casualty or

Mortuary Affairs office in the event of an AD or ARC service member’s death, MTF records

managers must notify the Air Force Service Treatment Record Processing Center via email at

usaf.jbsa.afmoa.mbx.str-processing-center@mail.mil that the Service Treatment Record is

sequestered. (T-1). If unable to forward original record, the Service Treatment Record Center

will accept a certified copy of the original record along with a notarized affidavit.

5.7.9.1. Service Treatment Records for Service Members Killed in Action. Immediately

following an AD service member’s death at an overseas battle zone or theater of operations,

the on-site Casualty or Mortuary Affairs office is authorized to take possession of the

remains and prepare the body for transport to the Dover Air Force Base Port Mortuary

Facility as soon as medical actions are complete. Available paper health treatment

documents and records must be surrendered to the Mortuary Affairs/Casualty Affairs

representative(s) upon request. (T-1). Document the records transfer using the appropriate

electronic records tracking mechanism.

5.7.9.1.1. If outpatient medical or dental treatment records are discovered (at a location

not specifically identified as the AD service member’s home-of-station support MTF),

after the remains have been transported to the Dover Air Force Base Port Mortuary

Facility, contact the nearest Casualty or Mortuary Affairs unit responsible for arranging

transportation of the remains. If medical and/or dental records cannot be transferred to

the nearest Casualty or Mortuary Affairs office, forward the medical record(s) to the

MTF responsible for the regular maintenance and storage of the deceased member’s

record. Contact the deceased service member’s deployed unit chain of command or

Personnel Support for Contingency Operations unit to ascertain from which installation

the Airman deployed. In the records package, include a completed AF Form 330, DD

128 AFMAN41-210 10 SEPTEMBER 2019

Form 2138 Request for Transfer of Outpatient Records or other appropriate form or

letter that informs the receiving MTF that, a) the AD service member has died, and b)

informs the receiving MTF the health records they received were intentionally

forwarded.

5.7.9.1.2. Home Station MTF Service Treatment Records Disposition Responsibility:

If notified by an official agency or unit (e.g., unit commander or chain of command

representative, installation Command Post, Mortuary or Casualty Affairs) that an AD

service member was killed in action while deployed, remove the deceased service

member’s outpatient medical and dental records from the main file and contact the

installation Casualty or Mortuary Affairs office. Forward the Service Treatment

Record to the Air Force Service Treatment Record Processing Center according to

processes identified earlier within this section, no later than 30 days following

notification of the service member’s death. The Air Force Service Treatment Record

Processing Center will digitize the Service Treatment Record in HAIMS, thus making

it available to the VA. (T-1). Surviving family members may be eligible for Service

or VA death benefits or compensation. The deceased Airman’s Service Treatment

Record may be required as part of the VA death benefits or compensation evaluation.

If, at any time, while preparing to ship the Service Treatment Record to the Air Force

Service Treatment Record Processing Center, the installation Mortuary or Casualty

Affairs unit, or Air Force Institute of Pathology specifically requests the outpatient

medical or dental records for official purposes, provide a certified copy of the Service

Treatment Record.

5.7.9.2. Service Members Placed in Appellate Review Leave Status or When a Prisoner is

transported to a Correctional Detention Facility Immediately Following a Trial.

5.7.9.2.1. Appellate Review Leave. Under the Uniform Code of Military Justice, a

punitive service discharge or dismissal may not be executed until the appellate review

is completed. During this appellate process, service members are still entitled to AD

healthcare benefits and are required to remain enrolled in TRICARE Prime. The

appellate process can sometimes be quite lengthy and requires the service member to

be placed on an involuntary excess leave status called “Appellate Review Leave.” The

following guidance provides instruction on how to manage the enrollment and medical

records of members on appellate review leave.

5.7.9.2.2. Service members subject to appellate review may relocate and reside

anywhere within the CONUS, to meet unique administrative and personnel

accountability requirements. Service members placed on appellate review leave are

assigned to the Air Force Security Forces Center (AFSFC), Joint Base San Antonio

(JBSA) Lackland, TX.

5.7.9.2.3. While on appellate review leave, the service member must remain enrolled

in TRICARE Prime and be enrolled to a MTF. (T-0). If the service member relocates

to another area, prior to departure the servicing MTF must brief the member on the

processes required for obtaining health care for themselves and any dependents. (T-0).

Service members on appellate leave cannot enroll into TRICARE Prime Remote or

choose a civilian Primary Care Manager. Reference 32 CFR Part 199.17. Also, see

Section 2A for additional information on enrollment.

AFMAN41-210 10 SEPTEMBER 2019 129

5.7.9.2.4. When a member is placed on appellate leave, the service member’s Service

Treatment Record will be forwarded (in a sealed envelope) to the Wilford Hall

Ambulatory Surgical Center at Lackland Air Force Base, TX where it will be

maintained until the appellate review period has completed. (T-1).

5.7.9.2.5. If the service member is available to complete MTF out-processing actions,

obtain or reproduce two copies of the individual’s discharge orders and follow the steps

identified below.

5.7.9.2.5.1. Place one copy in a charge-out guide.

5.7.9.2.5.2. Locate and retrieve the service member’s outpatient medical record.

5.7.9.2.5.3. Place the second copy of the discharge orders inside the record and file

the document in Section II on top of all other medical documents.

5.7.9.2.5.4. Locate and retrieve the dental treatment record – bundle together with

the Outpatient Medical Record.

5.7.9.2.5.5. Properly TRANSFER/INACTIVATE the medical records in the

CHCS Medical Records Tracking menu. Select “APPELATE LEAVE” or create

another easily identifiable records location destination that clearly distinguishes

these types of medical records from medical records transferred to the 59th Medical

Wing under routine PCS transfer rules. See the Medical Record Tracking,

Retirement and Retrieval User Guide on the AFMOA Health Benefits Kx to learn

how to create or set-up new records borrower/destination locations.

5.7.9.2.5.6. Place the complete Service Treatment Record in shipping package.

5.7.9.2.5.7. Prepare, complete, and sign an AF Form 330 and insert the form into

the package. Keep a copy of the AF Form 330.

5.7.9.2.5.8. No later than three days following the start of the appellate review

period, mail the complete Service Treatment Record and AF Form 330 to the

address identified below: following the steps outlined in paragraph 5.29.5.5.

Wilford Hall Ambulatory Surgical Center

ATTENTION: Lackland STR Manager

1100 Wilford Hall Loop

JBSA-Lackland Air Force Base, TX 78236-9908

5.7.9.3. Upon completion of the appellate review, if the service member is officially and

permanently discharged from the Service, the member’s name will appear on the

installation personnel LOSS roster for Lackland Air Force Base. The records department

at Wilford Hall Ambulatory Surgical Center is responsible for forwarding the original

Service Treatment Record to the Air Force Service Treatment Record Processing Center.

If the service member is removed from appellate leave and returned to duty, Wilford Hall

will transfer the original Service Treatment Record to the service member’s previous

assignment support MTF or to another MTF based upon written direction or orders. (T-1).

Medical records personnel will not release or forward the Service Treatment Record to

anyone, any place, or any agency without obtaining written direction or orders. (T-1).

130 AFMAN41-210 10 SEPTEMBER 2019

5.7.9.4. Prisoners Transported to a Correctional Detention Facility Immediately Following

Court-Martial Trial. Following the court’s Ruling and/or Sentencing, a service member

may be immediately escorted to a correctional detention facility.

5.7.9.4.1. During the appellate review period, even if a service member is immediately

transported to a correctional facility, the MTF where the service member’s Service

Treatment Record is normally maintained is responsible for forwarding the original

Service Treatment Record to Wilford Hall Ambulatory Surgical Center in accordance

with the instructions (associated with appellate review record disposition) previously

identified in this section. (T-1).

5.7.9.4.2. Records personnel at the service member’s support MTF and/or the Wilford

Hall Ambulatory Surgical Center are prohibited from providing or forwarding the

original Service Treatment Record to any prisoner escort detail or correctional facility.

(T-1). Instead, provide the escort detail or confinement facility with a complete Service

Treatment Record copy. If a copy cannot be immediately provided, a copy will be

mailed to the destination military correctional facility within five duty days. (T-1).

Copies of Service Treatment Records may be mailed to state and federal prisons upon

proper request. If available, obtain a copy of the service member’s orders or court

confinement order from the prisoner escort detail.

5.7.9.4.3. Address questions concerning this program to the Records Management

Support Team, AFMOA/SGAT at usaf.jbsa.afmoa.mbx.str-processing-

[email protected]il.

5.7.9.5. United States Air Force Academy Cadets and Airmen with Less than 180 days of

Continued Service. This applies to members of the United States Air Force Academy and

all other Air Force recruits separated or discharged prior to accruing 179 days or less days

of military service. Forward Service Treatment Records for these two beneficiary

categories to the Air Force Service Treatment Record Processing Center. Follow the same

Service Treatment Record disposition instructions as identified for AD and ARC service

members identified earlier in this manual. Place a copy of the separation or retirement

order or personnel document ordering the separation, discharge, or retirement inside the

Service Treatment Record.

5.7.10. NATO Military Personnel and NATO Family Member Non-Service Treatment

Records. Deliver outpatient records of NATO military personnel and their family members in

a sealed envelope to the individual concerned upon transfer to another United States military

base. Upon return of personnel to the NATO country, transfer records to the specific national

military medical authority. Address questions concerning this program to the Records

Management Support Team, AFMOA/SGAT at [email protected]il.

5.7.11. Non-NATO Foreign Military Personnel Non-Service Treatment Records. Retire

outpatient records for non-NATO foreign military personnel to National Personnel Records

Center two years after the end of the calendar year of the last date of treatment, in accordance

with AFRIMS Records Disposition Schedule, Series 41 Internet website, accessible via the Air

Force Portal website, and the Medical Record Tracking, Retirement and Retrieval User Guide,

available for download on the AFMOA Health Benefits Kx.

AFMAN41-210 10 SEPTEMBER 2019 131

5.7.12. Non-military (including family members and retired personnel) Non-Service

Treatment Records. Air Force MTFs are required to at least annually (no later than the end of

the same month from the previous year’s record retirement), retire or purge outpatient medical

records for family members and retired personnel to the National Personnel Records Center

Annex, 1411 Boulder Boulevard, Valmeyer, IL 62295. If records were last retired in April

2010, the next records retirement process should be completed by 30 April 2011. Retire

records two years after the end of the calendar year of the last date of treatment. Note: Do not

use the most current treatment date identified inside the paper health record. Review the

patient’s appointment history in the electronic health record. Retire or purge records in

accordance with AFRIMS Records Disposition Schedule, Series 41, accessible via the Air

Force Portal website and the Medical Record Tracking, Retirement and Retrieval User Guide,

available for download on the AFMOA Health Benefits Kx.

5.7.13. Non-Service Treatment Records for Family Members of Service Members Assigned

to GSU. Outpatient medical records are usually maintained at the MTF for two years after the

calendar year in which the last treatment occurred. However, this rule does not apply to Non-

Service Treatment Records for family members of service members assigned to a GSU, and/or

enrolled to TRICARE Prime Remote. As such, a family member’s Non-Service Treatment

Record may be kept on file at the MTF closest to the service member’s GSU TRICARE

enrollment. If this is the case, there may be no evidence in either the military electronic health

record or paper health record to indicate the family member has received MTF care within the

last two years. If records personnel suspect a family member, for whom the MTF maintains

an outpatient medical record, may be receiving care at a civilian network healthcare provider,

the record technician researching the record must verify the sponsor and family member

TRICARE enrollment status via DEERS. (T-1). If the enrollment information indicates the

family member is enrolled into TRICARE Prime Remote, then flag the outpatient medical

record according to the instructions in paragraph 5.15. If the DEERS information indicates no

TRICARE Prime or Prime Remote enrollment, then retire the record(s).

5.7.14. Federal Civilian Employee Non-Service Treatment Records. Federal Civilian

Employee Non-Service Treatment Records are maintained in SF 66D, Employee Medical

Folder and is a chronological, cumulative record of occupational and non-occupational

information pertaining to the health of a civilian employee during the course of employment.

A SF 66D can be obtained at https://www.gsa.gov.

5.7.14.1. This record consists of personal and occupational health histories, exposure

records, medical surveillance records, Office of Worker’s Compensation Programs

records, and the documented notes, evaluations and tests results generated by healthcare

providers in the course of examination, treatment and counseling.

5.7.14.2. Maintain Non-Service Treatment Records of civilian Air Force employees until

the employee is transferred to another activity within the Federal government or is

separated from the Federal Service. Upon employee transfer or separation, forward the SF

66D to the Military Personnel Section, Civilian Personnel Section within 10 days of

transfer or separation.

5.7.14.3. It is the responsibility of the Military Personnel Section to forward the Non-

Service Treatment Record to the appropriate custodian. However, federal civilian

132 AFMAN41-210 10 SEPTEMBER 2019

employees must complete installation and unit and/or installation out-processing checklists

similar to their AD counterparts (as applied to MTF out-processing requirements). (T-1).

5.7.14.4. Typically, AD members are required to visit the installation Outpatient Record

department to make sure their record(s) and the record(s) of their family members will be

forwarded to the next base, regardless of any pre-arranged Military Personnel Section -

MTF transfer process.

5.7.14.5. Federal civilian employees are also required to visit the local servicing MTF

Outpatient Record department where their Non-Service Treatment Record is maintained.

This process will ensure that the MTF receives notice from the civilian employee of an

upcoming transfer or retirement, regardless of any Military Personnel Section records

relocation/retirement notification.

5.7.14.6. Information regarding creation and maintenance of these Non-Service Treatment

Records is available for download on the AFMOA Health Benefits Kx.

5.7.14.7. If civilian employee records are found years after the employee has relocated or

retired, then:

5.7.14.7.1. Ensure records are in a SF 66D. Each employee will have his own folder.

5.7.14.7.2. Annotate the SF 66D with the employee’s last name, first name, middle

initial and Social security number on the upper right hand corner - preferably typed on

a white folder tab.

5.7.14.7.3. Box the records in a container which will safely make it through the United

States Postal Service mailing process.

5.7.14.7.4. Create a shipping list for each container. Detail the contents by name and

Social security number of each employee’s record. A SF 135, Records Transmittal and

Receipt is not needed.

5.7.14.7.5. Mail the container(s) to:

National Personnel Records Center Annex

1411 Boulder Boulevard

Valmeyer, IL 62295

5.7.14.7.6. Mail the record containers using standard first class mail, certified mail, or

other available option. If standard first class United States Postal Service is used, return

receipt confirmation is required.

5.7.15. Retirement of Inpatient Records, Extended Ambulatory Records, and Fetal Monitor

Strips to National Personnel Records Center. Additional information regarding creation and

maintenance of these records is available for download on the AFMOA Health Benefits Kx.

5.7.15.1. Inpatient Records. Retire inpatient records of all service members and their

family member dependents to National Personnel Records Center, in accordance with

AFRIMS Records Disposition Schedule, Series 41 Internet website, accessible via the Air

Force Portal website and the Medical Record Tracking, Retirement and Retrieval User

Guide available for download on the AFMOA Health Benefits Kx.

AFMAN41-210 10 SEPTEMBER 2019 133

5.7.15.1.1. Dispose or retire inpatient records according to the year of hospitalization

discharge, not date of admission.

5.7.15.1.2. Teaching facilities will retire records 5 years after the end of the calendar

year of the last date of treatment unless a waiver to retire earlier has been approved by

the Air Force Records Officer and National Personnel Records Center. Contact

AFMOA/SGAT for assistance when requesting a waiver. Non-teaching MTFs will

retire inpatient records one year following the end of the calendar year of the last date

of treatment.

5.7.15.2. NATO Military Personnel Inpatient Records: in accordance with NATO

Standardization Agreement for Basic Military Hospital (Clinical) Records, Inpatient and/or

Clinical records will accompany the patient upon transfer between hospitals, and will be

forwarded to the patient’s specific national military medical authority. See NATO

STANAG, Basic Military Medical Record, AMedP-8.2 Edition B, 15 January 2018.

5.7.15.3. Non-NATO Military Personnel Inpatient Records: Retire inpatient records in

accordance with AFRIMS, Records Disposition Schedule, Series 41 and the Medical

Record Tracking, Retirement and Retrieval User Guide, available for download on the

AFMOA Health Benefits Kx.

5.7.15.4. Extended Ambulatory Records. The retirement rules for extended ambulatory

records are the same as those for inpatient records. For teaching MTFs, the extended

ambulatory record should be retired five years following the end of the calendar year of the

last documented episode of care unless a waiver to retire earlier has been approved by the

Air Force Records Officer and National Personnel Records Center. Contact

AFMOA/SGAT for assistance when requesting a waiver. For non-teaching facilities, the

extended ambulatory record will be retired one year after the end of the calendar year of

the last documented episode of care.

5.7.15.4.1. Retire the extended ambulatory record folder to National Personnel

Records Center along with the inpatient records and any applicable fetal monitor strips

(i.e., in the same box.)

5.7.15.4.2. Place the extended ambulatory record folder behind any fetal monitor strips

for that patient, or behind the applicable inpatient record folder if there are no fetal

monitor strips.

5.7.15.4.3. If the patient does not have an inpatient record but does have an extended

ambulatory record, the extended ambulatory record is still included in the shipment of

inpatient records.

5.7.15.5. Fetal Monitor Strip. Retire the fetal monitor strips to National Personnel Records

Center in accordance with AFRMS Records Disposition Schedule, Series 41 Internet

website, accessible via the Air Force Portal website and the Medical Record Tracking,

Retirement and Retrieval User Guide, available for download on the AFMOA Health

Benefits Kx. (Note: Digitized, or other format, fetal monitor strips that can be printed out

on an 8 ½” X 11” sheet of paper are filed in the infant’s inpatient record or the mother’s if

the infant is stillborn and are retired as a part of the inpatient record).

134 AFMAN41-210 10 SEPTEMBER 2019

5.7.15.5.1. Retire the fetal monitor strips to National Personnel Records Center using

the same disposition schedule as that for inpatient records.

5.7.15.5.2. Attach the envelopes containing the fetal monitor strips to the inside of an

appropriately labeled folder (only two envelopes per patient per folder).

5.7.15.5.3. Annotate the outside of the folder with the name and register number of the

infant, sponsor’s name and Social security number, name of the MTF and date of

infant’s birth.

5.7.15.5.4. File these folders in the same box as the applicable inpatient record (baby’s

or mother’s) directly after that record.

5.7.16. General Inpatient Records Disposition Procedures:

5.7.16.1. Prepare National Personnel Records Center required index of records shipment

file. Outpatient and Inpatient medical records require separate indexes (fetal monitor strips

and extended ambulatory records must be included on the Inpatient records index). (T-3).

5.7.16.2. Follow the applicable tables and rules in accordance with AFRIMS, Records

Disposition Schedule, Series 41, to determine record retirement eligibility.

5.7.16.3. Utilize the step-by-step instructions provided in the Medical Record Tracking,

Retirement and Retrieval User Guide to create/run the retirement index. The Medical

Record Tracking, Retirement and Retrieval User Guide is available for download on the

AFMOA Health Benefits Kx. Address questions concerning this program to the Records

Management Support Team, AFMOA/SGAT at [email protected]il.

5.7.16.4. The CHCS will maintain shipment indices until all records listed have been

destroyed or transferred to the National Archives, or when no longer needed, whichever is

later. For future use, print and maintain a copy of each index. This information is

invaluable when determining whether or not a record has been retired to National Personnel

Records Center.

5.7.16.5. Forward a copy of each shipment index to the Base Records Management Office

for their files.

5.7.16.6. Requests for Medical Records from the National Personnel Records Center.

5.7.16.6.1. When requesting medical records retired to National Personnel Records

Center prior to CY 2003, use the DD Form 877-1, Request for Medical/Dental Records

from the National Personnel Records Center (NPRC) (St Louis, Missouri) or other

specific form identified by National Personnel Records Center records managers.

National Personnel Records Center request forms contain space for the minimal

information required for their agency to institute a search for the requested record.

5.7.16.6.2. To obtain medical records retired to the National Personnel Records Center

from CY 2003 and beyond, use the National Personnel Records Center Medical

Registry System to request the record(s). This computer application can be accessed

through a web interface. To register, requesting MTF personnel must complete the VA

Form 9957, ACRS Time Sharing Request Form. (T-2). An electronic version of the

form along with instructions for completion can be obtained at the Medical Registry

System website at https://www.archives.gov/st-louis/military-

AFMAN41-210 10 SEPTEMBER 2019 135

personnel/agencies/medical-registry-system.html. Additionally, MTF personnel

may use the step-by-step records retrieval instructions provided in the Medical Record

Tracking, Retirement and Retrieval User Guide available for download on the AFMOA

Health Benefits Kx.

5.7.16.6.3. Use the DD Form 2138 or 877, Request for medical/Dental Records or

Information when requesting records from another MTF.

5.8. Base Closures and Medical Records Management.

5.8.1. Inpatient Records are retired to the National Personnel Records Center upon

inactivation of the hospital (or upon downsizing to a clinic) in accordance with AFRIMS

Records Disposition Schedule at https://www.my.af.mil/afrims/afrims/afrims/rims.cfm and

the Medical Record Tracking, Retirement and Retrieval User Guide available for download on

the AFMOA Health Benefits Kx website and the AF/SG’s Contingency Operations Plan.

Reference AFI 41-106, Medical Readiness Program Management.

5.8.2. If early retirement is desired (i.e., out of cycle), the MTF commander or director must

request early retirement from Secretary of the Air, Chief Information Officer, Compliance

Division (SAF/CIO A6XA). (T-1). Coordinate the request with the local Information

Management Office before submission.

5.8.3. Submit requests for early retirement as soon as possible because of the time required

for approval. The request is coordinated with National Personnel Records Center who will

notify the MTF commander or director of the decision. The request must include the following

(T-3):

5.8.3.1. Reason for request.

5.8.3.2. Closure date (or date realigning to a clinic).

5.8.3.3. Type(s) of records to be retired.

5.8.3.4. Number of records (volume) involved.

5.8.3.5. All information normally included on the shipment index when requesting an

accession number from National Personnel Records Center.

5.8.4. Health records of AD members and their family members are transferred to the

member’s gaining base.

5.8.5. Health records of retirees and others are transferred as follows:

5.8.5.1. If another MTF is identified by the patient as the new facility of treatment, forward

the health records to that facility with a cover letter explaining why the records were

forwarded.

5.8.5.2. If a civilian medical facility is identified as the new treatment facility, copy

pertinent portions of the record for the patient to take to that facility. Retire the original

record to National Personnel Records Center in accordance with AFRIMS Records

Disposition Schedule and the Medical Record Tracking, Retirement and Retrieval User

Guide. Maintain an AF Form 1942 for six months or until the base closes, whichever

comes first, then destroy.

136 AFMAN41-210 10 SEPTEMBER 2019

5.8.6. For sequestered records, each MAJCOM will designate repository bases within the

command to administer medical records involved in projected or active litigation.

5.8.7. If a medical malpractice claim was filed for AD family members, forward the original

inpatient or outpatient record (as applicable) to the Risk Manager or Hospital Administrator at

the gaining MTF. Do not allow the patient to hand-carry the record. In addition, send a letter

explaining why the records are being forwarded.

5.8.8. Use the following guidance if a medical malpractice claim was filed for a retiree or

other patient.

5.8.8.1. If the continued care will be provided at an Air Force MTF, forward the original

record with the appropriate letter of explanation.

5.8.8.2. If the care will be provided by a civilian or non-Air Force MTF, provide the patient

with a copy of the record and forward the original with the appropriate letter to the Risk

Manager or Medical Facility Administrator at the designated repository.

5.8.9. Use the following guidance for potential claims.

5.8.9.1. If there is a potential claim in reference to inpatient records, forward the original

inpatient record with the accompanying letter of explanation to the Risk Manager or

Quality Services Manager at the gaining Air Force MTF or designated repository base.

5.8.9.2. If there is a potential claim in reference to outpatient records, as a general rule,

follow procedures outlined in this section. Coordinate special concerns and circumstances

with the local base Staff Judge Advocate. Maintain the record in a sequestered location.

5.8.10. Closure bases must establish a “Chain of Custody” document that lists each patient’s

name, Social security number, DoD Identification Number and location to which the medical

record was forwarded. (T-3). Forward a copy of the Chain of Custody document to the

MAJCOM command surgeon and the Records Management Support Team, AFMOA/SGAT.

5.8.11. Upon inactivation of the MTF, the old retained SF 135s, (these were produced prior to

CY 03) and copies of the CHCS shipment indices (produced CY 03 and later) will be forwarded

to the next higher records management office at the MAJCOM command surgeon’s office and

the Records Management Support Team, AFMOA/SGAT.

5.9. Health Record Review Committee/Functions.

5.9.1. Record review functions will be performed at each MTF by either an established

Medical Record Review Committee or incorporated into other committees that review records.

(T-1). Record review function examines and evaluates the following: record quality and

clinical pertinence; information assurance practices; and, inpatient and outpatient records

completion times. Also examined are whether the records are prepared and maintained

according to directives and Joint Commission standards. Finally the records review function

is the approval authority for locally created forms. (T-0). Cross-service representation will be

included in the performance of these committees, i.e., representatives of the various clinic

services, dental services, nursing services, medical record departments, management and

administrative services, and other departments, as appropriate. These review functions are part

of the Air Force Quality Assurance program. Reference under DoDI 6025.13, Medical Quality

Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS).

Responsibilities of this committee will include but not be limited to the following items (T-0):

AFMAN41-210 10 SEPTEMBER 2019 137

5.9.1.1. Cross-Functional Sampling of Clinical Documentation: The review function

should include an adequate number of both inpatient and outpatient records (sampling ratio

should represent clinical facility workload levels). For example: Provider monthly

workload < 30, review 100% of cases; Workload = 30-100, review 30 cases; Workload =

101-500, review 50 cases; Workload > 500, review 70 cases. Records will be reviewed to

ensure the highest possible standards of quality control, record completion periods,

legibility, promptness in documentation, and clinical pertinence are met. Records of recent

deaths, hospital infections, complications and unusual problem cases are reviewed. A

representative sample of records from every provider will be reviewed throughout the year.

5.9.1.2. Review the monthly medical record availability and accountability rates and

report to the Executive Committee of the Medical Staff or as directed by the MTF

commander or director.

5.9.1.3. Review the Service Treatment Record disposition process and progress on

meeting the standards of completeness and timeliness and report to the Executive

Committee of the Medical Staff or as directed by the MTF commander or director.

5.9.1.4. Written reports of the review function contain conclusions, recommendations,

actions taken and after-action results. These data reports are quality assurance records.

These data reports are then forwarded to the Executive Committee of the Medical Staff for

review or as directed by the MTF commander or director.

5.9.2. Committees tasked with records review must approve locally overprinted SFs filed in

health records. (T-2). Overprints are authorized only when the material added does not conflict

with the purpose for which the form was intended. See AFI 33-360 and DoD 7750.07-M for

further instructions on the authorized use of overprinted forms.

Section 5B—Outpatient Records Administration

5.10. Creation of Outpatient Record Folders. The AFMS no longer creates hard copy

outpatient record folders. Outpatient records will be created and maintained in the approved

electronic health record. (T-0). Arrangement of content, record filing methodology and use of

electronic health records are consistent throughout Air Force MTFs. For those existing hard copy

original paper medical records in the MTF that may need a replacement folder see Table 5.1 for

preparing outpatient records folders and Attachments 6, 7, 8 and 9.

Table 5.1. Preparing Outpatient Record Folders Table.

If the patient is:

Use Social security number of:

AD/ARC

Member

Family Member

Sponsor

Family Member and RC Service Member

Sponsor

Civilian Employee

Employee

Retired Military

Retired Military (Note paragraph

5.10.4.)

Civilian Emergency

Patient

5.10.1. Dual eligibility presents a concern for both medical records personnel and clinicians.

Medical records personnel must ensure that the correct Social security number is used when

138 AFMAN41-210 10 SEPTEMBER 2019

creating the Service Treatment Record/Non-Service Treatment Record for a dual eligible

member who presents for care at the MTF. (T-0). In accordance with DoDI 1000.13 and AFI

36-3026_IPV1, medical records personnel will create a record based upon the highest level of

eligibility. (T-0). Refer to paragraph 4.7 for additional information regarding multiple same-

patient dual eligibility situations. However, for this section, the two most notable dual eligible

scenarios that usually apply to medical records are covered:

5.10.1.1. A dependent who is also a member of the RC. Usually, in this instance, the

dependent is a spouse of another AD or retired military member. However, another

possibility may indicate that the dependent is a child (son or daughter); under 21 years of

age or under 23 years of age if enrolled in a full-time college program.

5.10.1.2. The second likely scenario may be a dependent spouse who is also a retired

military member.

5.10.2. Generally, medical records personnel should create a record based upon the highest

level of eligibility. If a cross-reference situation exists, specifically for family members who

are also RC service members, locate the block labeled, “Specify Service & Grade for Military

& Retired Military Member,” near the middle of the front of the outpatient medical record

jacket. Of the three categories, select the NONMILITARY category. This is the selection that

should correspond to the patient’s primary MTF dependent empanelment status. Then blot the

corresponding square/block. Next, print the member’s dependent status and Social security

number here and status as a member of the AFR or ANG, or other multi-service RC as

appropriate. Additionally, print in black felt-tip marker or stamp the words, “CROSS-

REFERENCE” in 2-inch block letters on the upper left side of the front of the jacket.

5.10.3. Outpatient medical and dental records for (Category A) RC service members are

usually maintained with the member’s reserve unit. Already existing paper based records will

be maintained as listed below. Only create one electronic health record per dual eligible

patient. If the RC service member is also a family member-dependent, another outpatient

medical record should be created at the servicing MTF to document all medical care the patient

received under the dependent patient category. The following provides guidance for

establishing two record volumes – using 000-00-0000 as the patient’s Social security number

and 999-99-9999 as the sponsor’s Social security number:

5.10.3.1. Volume 1 will be the primary record used for the dependent information (30/999-

99-9999). Dependent documentation will be filed in this record jacket (99-RED). The

label should be the printed label from CHCS (30/999-99-9999). Write “CROSS-

REFERENCE” on the cover and annotate RC/AD family member prefix/social security

number 20/000-00-0000.

5.10.3.1.1. File the record in the main central file with a Charge-out Guide. Inside the

guide place a word document referring to the separate RC record, e.g., “STOP! This

member is also a Reservist/Individual Mobilization Augmentee/ANG Member.

Separate RC record maintained on xxxxxx shelf.”

5.10.3.1.2. In the small pocket where the AF Form 250 would go, print/place an extra

label from CHCS that states where to re-file the guide on the shelf.

5.10.3.2. Volume 2 will be the record used for the RC/AD paperwork (20/000-00-0000).

Activated RC service member documentation will be filed in this jacket (00-ORANGE).

AFMAN41-210 10 SEPTEMBER 2019 139

The label can be handwritten OR, if printed label from CHCS is used, cover the 30/999-

99-9999 family member prefix/social security number with a label or white tape and

annotate the correct family member prefix/social security number for this record (20/000-

00-0000).

5.10.3.2.1. Write “CROSS-REFERENCE” on the cover and annotate “RC/AD family

member prefix/social security number 20/000-00-0000.”

5.10.3.2.2. File the record in a separate location from the main central file.

5.10.3.3. When records are retrieved for appointments by exception, pull both volumes,

the dependent record and the RC/AD record, and wrap a rubber-band around both record

volumes. Ensure the clinic staff knows in which record to annotate the encounter.

5.10.4. Military retired patients who are also eligible for care as a dependent spouse may

produce a unique situation when selecting appropriate CHCS automated system registration

formats and when creating the corresponding outpatient medical record. Generally, medical

records for dual or multiple healthcare eligibility patients should be created using the family

member prefix and social security number that corresponds to highest level of eligibility or

according to the patient category that is most advantageous to the patient.

5.10.5. If a beneficiary has received medical care under a previous social security number as

a result of remarriage to another military sponsor, record forms filed under the former Social

security number should be consolidated under the current sponsor Social security number.

Once the patient has been registered in CHCS under the current sponsor’s Social security

number, merge the old and new patient file. For future inquiries, a cross-reference from the

old number to the new number should be indicated in the outpatient files as well as in the

current automated system.

5.10.6. A temporary or pseudo Social security number may be created for beneficiaries

without a Social security number. This process occurs in DEERS when the personnel

technician issues an identification card or enters the beneficiary into DEERS. Either a Foreign

Identification Number or a Temporary Identification Number is generated.

5.10.7. Civilian Emergencies. No paper based records will be created for civilian

emergencies. Already existing records will be filed by Social security number in a manila

folder and maintained separately from the main file if desired. However, they must be

interfiled by Social security number with the rest of the records when retired to National

Personnel Records Center. (T-1).

5.10.8. Civilian employees [including Air Reserve Technicians] who are also members of a

RC will have one medical record maintained as indicated in paragraph 5.14. The only

exception will be if the individual is not employed as a civilian at the same base where the

individual’s RC unit is assigned. In these cases, a civilian medical record will be maintained

as described in the beginning of this paragraph. Civilian employees who are also assigned to

a Personnel Reliability Assurance Program/Presidential Support Program or Sensitive Duties

Program position or job will have one medical record maintained as indicated in paragraph

5.12.5.7 until such time as they are removed from the program or are transferred to another

federal agency or separated from federal service.

140 AFMAN41-210 10 SEPTEMBER 2019

5.10.9. When individuals who are not attached to the base are receiving medical care on base

(for example, Air Force Institute of Technology (AFIT) students), identify their records by

entering their status on the record folder, in pencil. Do not forward these records except at the

patient’s specific request.

5.11. Labeling File Folders.

5.11.1. AF Forms 2100A Series, Forms 2100A, 2110A, 2120A, 2130A, 2140A, 2150A,

2160A, 2170A, 2180A and 2190A, Health Record – Outpatient.

5.11.2. Select an Air Force form in the 2100A series according to the last two digits of the

applicable Social security number:

Table 5.2. Terminal Digit Health Record Filing System.

Last two digits of Social

security number:

Use AF Form:

00-09

2100

10-19

2110

20-29

2120

30-39

2130

40-49

2140

50-59

2150

60-69

2160

70-79

2170

80-89

2180

90-99

2190

5.11.3. Print the first name, middle initial, and last name of the patient in the space provided

with a black pen or black felt-tip marker. Address labels prepared by the Personnel Data

System may be used to provide names of military personnel. Do not use pencil for any entry

except rank. Always place information in the upper right-hand corner of the cover in the

patient Identification area.

5.11.4. Print the sponsor’s Social security number in the preprinted blocks in the upper right-

hand corner of the record.

5.11.4.1. Print the family member prefix in the two circles next to the Social security

number. Check the TRICARE DEERS website for the DEERS Dependent Suffix for the

patient or if not available, number in birth date order for family member children.

5.11.4.2. The family member prefix will not change as long as the patient is still associated

with the same sponsor and social security number.

5.11.4.3. When a military member marries a person with children, assign family member

prefix numbers in sequence following the last family member prefix already assigned to

children of the sponsor (if any). Assign the oldest child the next number in numerical

sequence, etc.

5.11.4.4. Spouse Prefix Assignment: Assign the family member prefix “30” to the first

spouse authorized care. If the member remarries due to spousal death, divorce, etc., assign

AFMAN41-210 10 SEPTEMBER 2019 141

the number “31” to the next authorized current spouse. Increase prefix numbers by 1 (e.g.,

32, 33) for any additional dependent spouse authorized care. Only one current dependent

spouse is authorized medical care.

5.11.4.5. Un-remarried Former Spouses: All un-remarried former spouses are now self-

sponsored. Un-remarried former spouses who have met the requirements in accordance

with AFI 36-3026_IPV1 are treated in the MTF as their own sponsor. Create medical

records for these patients using a “20” family member prefix and the un-remarried spouse’s

own social security number. If the patient’s previous record, filed under the deceased

sponsor’s Social security number, is still in the file, remove the documents and place in

this new record. Annotate previous folder with cross reference to new folder. If the patient

is still in CHCS under the deceased sponsor’s Social security number, work with the

Systems Office to correct. See paragraph 2.7 for more definitive information regarding

authorized care for former spouses of military members.

5.11.5. Standard Folder Markings: Blot out the ½ inch square block, along the right edge of

the rear leaf of the folder that corresponds to the sponsor’s last Social security number digit.

Use a black pen, black felt-tip marker or ½ inch-wide black tape. If a pen or marker is used,

be sure to darken the digit block on the reverse side of the record jacket. For tape, cover the

appropriate digit on the front side of the folder, then fold an equal amount of ½ inch-wide tape

to the rear side of the folder and cover the digit on the reverse. Keep tape cuts neat and even.

5.11.5.1. Do not make any entries in the small preprinted, numbered blocks, the “R” and

“S” blocks at the top of the folder, or the “R” and “S” blocks on the side of the folder (these

are for Army use only).

5.11.5.2. On the front leaf cover, on the right side of the record jacket, blot out the year

that corresponds to the patient’s most recent documented visit with a black pen or black

felt-tip marker. Note: Do not prepare another folder if the available year selections on the

original record jacket fill-up. Attach AF Form 2700L, Health Record Year Grid, to AF

Form 2100A series over the old year markings.

5.11.5.3. Located near the center of the outside of the record jacket, in the block labeled,

Specify Service, Grade for Military and Retired Military Member, select the appropriate

category, blot the corresponding block, and document the patient’s status. Enter the

Service and rank for AD and retired military personnel. Enter the country for non-United

States military personnel. (A copy of the non-United States military member’s orders

should be placed in the health record). Use pencil for rank only. See paragraph 5.10.5 for

family members who are also members of the AFR or ANG.

5.11.6. Personnel Reliability Assurance Program/Presidential Support Program, or Sensitive

Duties Program Folder Markings: Use red pen, red permanent marker or red tape instead of

black to identify a Personnel Reliability Assurance Program/Presidential Support Program

member’s folder. Cover the appropriate last Social security number digit (both sides of the

record jacket) located along the folder’s right edge.

5.11.6.1. Stamp or label the outside of the record jacket with the abbreviation “PRP” or

“PSP” in approximately 2-inch red block letters. The stamp marking should be placed on

the left hand side of the front of the record jacket to identify persons who participate in the

142 AFMAN41-210 10 SEPTEMBER 2019

Personnel Reliability Assurance Program. Cover the red marking with a black marking or

black tape when a member is removed from the program. All other colors are unauthorized.

5.11.6.2. An AF Form 745 will be affixed to Section 2 of the active Volume of the

outpatient medical record. Note: In existing records, the use of the AF Form 745 in

closed/inactive volumes is authorized, but not required.

5.11.7. Aerospace or Flight Medicine Record Markings: To help identify patients in the

categories listed in paragraph 5.13.5., blot out with black pen, black felt-tip marker or place a

½ inch-wide strip of black tape along the right side of the folder beginning at the bottom of the

“9” block and end at the bottom of the folder. Cover the “R” and “S” blocks. One inch-wide

black tape may also be used. If using 1 inch-wide tape, place the tape on the folder so that half

of the strip folds to the rear side of the folder. If a marker is used, mark out the same distance

on the rear of the folder jacket. If the record is filed in a filing cabinet instead of on a shelf,

apply another narrow strip of black tape to the top edge of the rear folder leaf. Ensure the tape

strip covers both the “R” and “S.” Start tape strip over the left side edge of the first numerical

digit block of the sponsor’s last 4 digits of the Social security number and continue to the right

edge of the numerical digit block “9” at the top of the folder. Place the tape on the folder so

that half of the strip folds to the rear side of the folder. Never cover the family member prefix

or social security number.

5.11.7.1. Stamp or label the outside of the record jacket with the word “FLY” (ALL IN

CAPS) in approximately 2-inch black block letters. The stamp marking should be placed

on the left hand side of the front of the record jacket to identify persons who participate in

an aerospace/flying program or dependents of persons who participate in an

aerospace/flying program.

5.11.8. Stamping or labeling the front cover of the medical record with any large-letter

identifiers other than a) FLY, b) PRP or PSP, c) CROSS-REFERENCE, d) with infant-

adoption related notifications (see paragraph 4.3.3.1.) or, e) MEDICATION ALLERGIES is

discouraged.

5.11.9. If the patient is a food handler, the Force Health Management office enters the date of

the current food handler examination in pencil on the appropriate line of the preprinted format.

5.11.10. If the patient is allergic to medication, display this information prominently under the

patient identification data on the right hand side of the folder.

5.11.11. Attach the CHCS Medical Record Tracking bar code label to the health record folder

in the upper right hand corner. See the Medical Record Tracking, Retirement and Retrieval

User Guide for instructions on label requirements.

5.11.12. Acknowledgement of Notice of Privacy Practices. Each patient will receive a copy

of the MHS Notice of Privacy Practices. (T-0). See AFI 41-200, paragraph 3.2 for additional

information on providing the notice and documenting receipt. Reference DoDM 6025.18.

5.12. Contents of the Outpatient Record.

5.12.1. Outpatient records must contain enough information to identify the patient, support the

diagnosis/condition, justify the care, treatment, and service, accurately document the results of

care, treatment and service rendered, and promote continuity of care. (T-1). Documents will

contain the name and location of the MTF maintaining the record to ensure the document is

AFMAN41-210 10 SEPTEMBER 2019 143

sent to the proper MTF. (T-1). The documents will also contain the name of the outpatient

record location. (T-1).

5.12.2. Embossed plastic cards may be used to record patient identification information on

forms. Each document in the record contains, as a minimum, patient’s name, family member

prefix, full Social security number under which the record is to be filed, name of the MTF

maintaining the patient’s record, and name of the outpatient record location. The only

exception is the display sheet on which laboratory and x-ray slips are filed. Since the individual

slips contain the necessary data, it is not necessary to repeat identification information on the

same sheet. However, if the information is not there, it needs to be added.

5.12.3. Paperwork Filing Order for the AF Form 2100A Series, Health Record-Outpatient

(four-part folder). Refer to the tables located at attachment(s) 6-9 in this AFMAN.

5.12.4. Electronically generated forms.

5.12.4.1. Tri-Service Workflow is the standard documentation method for Patient

Centered Medical Home in Family Medicine, Internal Medicine, and Pediatrics for the

entire MHS.

5.12.4.2. No matter the form automation mechanism, when electronically generated forms

are used in place of SF, DD, or Air Force forms, each automated form must contain the

statement “SF, DD or AF Form XXXX (EF) [name and producer/vendor (if any) of the

software used].” (T-1). See Section 5A for guidance on overprinted and electronically

generated forms. Reference DoDI 7750.07-M.

5.12.5. Documenting the DD Form 2766 for AD Service Members/ RC Service Members –

Continuity of Care Documentation.

5.12.5.1. The DD Form 2766 is the primary folder used to document medical and dental

treatment for AD, AFR, ANG, and deployable federal civilian employees while in a

deployed environment. The original outpatient medical and dental records for each

deployed AD, RC service member and deployed federal employee remain at the host base.

During a deployment, the cardstock DD Form 2766 is the only authorized folder used to

document a service member or federal employee’s adult preventative and chronic care

history, unless exempted by COCOM/Component reporting instructions. During non-

deployment periods the DD Form 2766 is filed inside the service member’s outpatient

medical record. Federal civilian employees who have not deployed in support of a

contingency operation should not have a DD Form 2766. Reference DoDI 6490.03.

5.12.5.2. The Tri-Service Workflow Core Alternate Input Method form (“Tri-Service

Workflow Core”) in AHLTA will serve as the initial intake form for all primary care visits

(both AD and non-AD) and serves as the primary mechanism for communicating

continuum of care information between healthcare team members and MTFs.

5.12.5.3. MTF providers and clinical support staff are required to update the Tri-Service

Workflow Core continuum of care elements at each visit, but are not required to review or

update the cardstock DD Form 2766. If information is handwritten on the card stock DD

Form 2766, it should be validated and transferred to the Aerospace Services Information

Management System (ASIMS) DD Form 2766 for AD and ARC service members. The

form should then be marked (with a stamp or hand-printed in bold letters) “Data

144 AFMAN41-210 10 SEPTEMBER 2019

Transferred to electronic ASIMS Form 2766 on (insert date of transfer)” at the top of

each card stock page.

5.12.5.3.1. No medical information is to be hand-written on an ASIMS DD Form 2766

generated document. Information collected on the card stock DD 2766 during a

deployment will be merged with the electronic ASIMS DD Form 2766 within 30 days

following a service member’s return from deployment in accordance with DoDI

6490.03.

5.12.5.3.2. The electronic ASIMS DD Form 2766 will be updated during the annual

Periodic Health Assessment and/or from information obtained from pre and post-

deployment questionnaires, patient interviews, patient-provider encounters, clinical

reviews, and updated prior to any service member PCS. Unless, exempted by

COCOM/Component reporting instructions, the most current version of the ASIMS

DD Form 2766 and DD Form 2766C will be printed and placed into the cardstock DD

Form 2766 (secured with the metal prongs) for all AD and ARC service members

during pre-deployment screening, and prior to completing PCS out-processing for PCS

locations that do not utilize AHLTA. Insert a copy of the most current DD Form 2766

and DD Form 2766C into the cardstock DD Form 2766 for any Federal civilian

employee during the pre-deployment screening process.

5.12.5.4. Absent an automated DoD solution that captures and transfers the same

preventive and chronic care medical information from non-combat host MTFs to a

deployed theater location, the card stock DD Form 2766 will remain a permanent part of

the paper-based outpatient medical record. (T-3).

5.12.5.5. Immediately following the pre-deployment clinical review/screening, photocopy

all sections of the cardstock DD Form 2766 and file the copy in the original outpatient

medical record.

5.12.5.6. For service members assigned to Sensitive Duties Programs (e.g., Personnel

Reliability Assurance Program and Presidential Support Program), MTF records personnel

will attach an AF Form 745, inside the DD Form 2766 cardstock record at the time of

deployment. (T-3). Additionally, stamp “Personnel Reliability Assurance Program” or

“Presidential Support Program” in approximately 2-inch letters on the cover of the DD

Form 2766 prior to a service member’s deployment. Note: This only applies to existing

records.

5.12.6. Documenting Preventative and Chronic Care for Non-AD Adult Beneficiaries.

5.12.6.1. The Tri-Service Workflow Core template in AHLTA will serve as the initial

intake form for all primary care visits (for both AD and non-active-duty adult patients) and

serves as the primary mechanism for communicating.

5.12.6.2. Tri-Service Workflow Core will replace the need for completing the card-stock

DD Form 2766 for non-AD adult beneficiaries. (T-3). All discontinued DD 2766 forms,

already filed in the medical record, must remain in the outpatient medical record. (T-3).

Do not destroy old or seemingly irrelevant medical documents.

5.12.7. Documenting and Filing the DD Form 2882.

AFMAN41-210 10 SEPTEMBER 2019 145

5.12.7.1. This form will be used for all DoD TRICARE Prime pediatric and adolescent

beneficiaries to provide continuity of care in the TRICARE system. (T-3). The form may

also be used for non-TRICARE Prime pediatric and adolescent beneficiaries at the

discretion of the MTF or provider. The DD Form replaces the AF Form 4320. All AF

Forms 4320 and AF Forms 3923 already in the medical records must remain in the

outpatient medical record. (T-3). Do not destroy old or seemingly irrelevant medical

documents.

5.12.7.2. Pages one and two are mandatory for all newborns and all current Service

specific forms used for the summary of care that are worn, torn or which otherwise need to

be replaced. (T-3).

5.12.7.3. Pages 3 and 4 are used to track immunizations and are available for use if there

is not a Service specific form currently in use.

5.12.7.4. Pages 5, 6, and 7 are designed to track clinical preventive services, as identified

by the current edition of the United States Preventive Services Task Force Guide to Clinical

Preventive Services (https://www.uspreventiveservicestaskforce.org) and the

TRICARE Prime benefit package. This form is not intended to be used as current age-

specific recommendations for care of newborns through adolescence ages (0 - 18 years).

5.12.7.5. The DD Form 2882 is available in hard copy only. To obtain copies of the

current form, contact the MTF Forms Management Office.

5.12.7.6. Tri-Service Workflow Pediatric Alternate Input Method forms have replaced DD

Form 2882 for documentation of pediatric and adolescent preventive and chronic medical

information. Although DD Form 2882 has been replaced, it may still be present in original

paper medical records and utilized at locations that do not have access to AHLTA.

5.12.8. Documenting and Transcribing Information from Historical Patient Preventative and

Chronic Care Flow Sheets.

5.12.8.1. Health records support personnel are not authorized to transcribe pertinent

information from the old form to the new form. Only the patient’s Primary Care Manager

medical staff are authorized to transcribe pertinent medical information from this document

to the electronic health record or to another DD Form 2766.

5.12.8.2. Do not remove or destroy the old AF Form 1480, Summary of Care, 1480A,

Adult Preventive and Chronic Care Flowsheet (aka Summary of Care); DD Form 2766; or

DD Form 2882 from the paper outpatient medical record. Keep these documents in

outpatient medical record. Instead, for an outdated DD Form 2766 (from the current filing

position in part I of the AF Form 2100A Series Outpatient Medical record), close the form

and then double hole punch the bottom of the form/folder and replace the form back into

Section I with page 1 of 4 face-up.

5.12.8.3. For service members, place the new DD Form 2766 on top of the old form so

that the form can be opened inside the medical record. Non-AD adult beneficiaries do not

need a replacement DD Form 2766.

5.12.9. Unauthorized Storage of Second, Back-up, or Shadow Files. There will be only one

storage area for medical records. (T-0). Medical information which documents, illustrates,

depicts, or describes clinical data will not be stored in more than one MTF location. (T-0).

146 AFMAN41-210 10 SEPTEMBER 2019

This data includes but not limited to outpatient encounters, dental encounters, inpatient

healthcare, same day surgeries, ambulatory surgery, or diagnostic care. (T-0).

5.12.9.1. Official medical records and medical documents created to permanently

document the healthcare provided to a patient are maintained in either the electronic health

record or officially recognized rigid, cardstock record (for which an approved Air Force or

DoD record/form number exists). Copies of original medical or dental treatment records,

sometimes referred to a “back-up” or “shadow files” kept in any work center for the

purpose of convenience, quick reference availability, or to maintain a clinic mini-file

system, are unauthorized.

5.12.9.2. The minimum official record sets used by the AFMS include: outpatient

medical, dental treatment, inpatient, ambulatory procedure, extended ambulatory, and

mental health record folders. Any officially recognized paper/cardstock record(s) are

stored with like records in a central or decentralized, secure, limited access records file

room(s). Following each individual treatment or patient encounter, and only after all

necessary administrative and/or coding or quality review processes are complete, original

medical or dental treatment forms or records documenting provider-patient interaction, will

be placed or filed into the patient’s electronic health record or applicable cardstock medical

record. Copies will not be maintained anywhere. (T-0).

5.13. Filing Outpatient Records.

5.13.1. “Terminal Digit” Filing System: File records by Social security number, according to

a terminal digit, color-coded and blocked filing system. Divide the central files into 100 equal

sections. Establish a minimum of 100 files guides identifying primary Terminal Digit

numbers, “00” through “99.”

5.13.2. File record folders in numerical sequence according to their secondary numbers within

each section. The secondary number is the pair of digits immediately to the left of the primary

number.

5.13.3. All outpatient records and forms will be maintained in a single numerical file in a

central location except when the MTF commander or director authorizes decentralization of

the numerical file to the patient’s major primary or family care team location or to the Flight

and Operational Medicine Clinic, if applicable, see paragraph 5.13.5. (T-3). The numerical

files of personnel assigned to the Personnel Reliability Assurance Program, Presidential

Support Program or any other sensitive duty program are also maintained in a separate secured

location. See paragraph 5.13.6. In MTFs with authorized decentralized records rooms, the

CHCS Medical Record Tracking function will identify where the numerical file is regularly

stored and will document inter-facility borrower history. Use of AF Form 614, Charge Out

Record will not be required unless the CHCS Medical Record Tracking function is not used or

the MTF Records Custodian deems non-use appropriate.

5.13.4. Annual AD Inventory. MTFs will establish local procedures to perform an annual

inventory of all AD Air Force records by 31 March. (T-1). AFMOA will contact the local

Military Personnel Section and obtain a roster of all assigned and/or attached AD personnel

and provide a copy to medical records personnel. (T-1). Medical records personnel should sort

the roster by terminal digit order. If missing record(s) and/or volumes(s) are discovered during

AFMAN41-210 10 SEPTEMBER 2019 147

the initial audit, records personnel will perform monthly follow-up audits until the missing

record(s) and/or volumes(s) are retrieved or located. (T-1).

5.13.5. Flight and Operational Medicine Records: If authorized by the MTF commander or

director, outpatient records for Airmen and family members empaneled to the Flight and

Operational Medicine Clinic may be maintained in the Flight and Operational Medicine Clinic.

Flight and Operational Medicine records are usually maintained on individuals assigned to: air

crew duty, missile launch duty, air traffic control duty, physiological training duty, parachute

duty, and weapons control duty, and on the family members of Airmen on flight status who

are empaneled to the Flight Clinic.

5.13.6. Outpatient medical and dental treatment records for personnel assigned to the

Personnel Reliability Assurance Program, Presidential Support Program, or any other sensitive

duty program will be maintained in a separate, secured location. (T-3). Again, as mentioned

in paragraph 5.13.3., proper use and management of the CHCS Medical Record Tracking

module will provide MTF personnel with the mechanism to determine where a paper medical

record is located.

5.13.7. Outpatient and dental health records for authorized family members and sponsors who

reside at locations outside of approved MTF TRICARE PRIME enrollment prime service areas

or who are assigned to a) United States Air Force Recruiting Service posts, b) Reserve Officer

Training Corps (ROTC) units, c) GSU, d) authorized TRICARE Prime Remote locales, e)

health records for TRICARE Prime family members enrolled to civilian Primary Care

Managers and f) overseas United States embassy support will be maintained at the nearest

MTF to the member/sponsor’s remote assignment location or home address, whichever is more

advantageous to the sponsor and family member(s). There may be instances when the

responsible Air Force MTF is not the nearest MTF to where the member is assigned or the

family member is enrolled. In these instances, the responsible Air Force MTF must coordinate

with the nearest MTF maintaining the records to ensure the records are correctly processed

when the member retires, separates, receives a PCS to another location or enrolls to another

MTF. (T-2). Family members and sponsors will not hand-carry their Service Treatment

Records/Non-Service Treatment Records to these locations. (T-0). See paragraphs 5.15 and

5.29 for additional instructions.

5.13.8. Splitting Records aka Closing Record Volumes: In order to optimize file space for

current and future outpatient records, it is permissible to split or separate outpatient records

that consist of more than one volume.

5.13.8.1. If an additional record volume is needed or to separate the current volume from

older volumes, records personnel will mark on the front cover of the new outpatient record

volume jacket cover, in the upper left corner or in another area where other identifying

record information is not obscured, in 2” capital letters, with bold, black marker, the

appropriate volume number, e.g., “Volume 2, 3, or 4” or “Volume II, III, or IV,” etc. (T-

3).

5.13.8.2. Login to CHCS and from the Medical Record Tracking module, verify that the

multi-volume record is properly referenced, and if not, create a new electronic volume

reference, print a new bar-scan Identification label and affix to the new record volume

jacket in the upper right corner.

148 AFMAN41-210 10 SEPTEMBER 2019

5.13.8.3. Place the new record volume back into main file and relocate older volume(s) to

a designated location within the secure records department. Label older volume(s) with

the same type of bold, black marker, clearly indicating the volume number and be sure the

bar-scan Identification label reflects the older volume number(s).

5.13.9. Deceased Patients: Place outpatient records of deceased patients in a separate, secured

file location within the records department. Retire the non-AD medical record to the National

Personnel Records Center in accordance with established record retirement procedures. For

records of deceased AD and RC service members, refer to the Sequestered/Deceased

Member’s Records. See paragraph 5.7.2.

5.13.10. Use of AF Form 1942, to manage records is optional. However, if a MTF Records

Custodian chooses to continue using the form, prepare and maintain an AF Form 1942 for each

record permanently forwarded to another facility. Keep the form in an alphabetical file for 180

days, and then destroy. See paragraph 5.29 for further information regarding permanently

transferring medical records to other MTFs.

5.13.11. Record custodians will comply with Air Force records management and maintenance

instructions when maintaining Army and Navy records. (T-1).

5.13.12. When personnel from the United States Army and United States Navy are:

5.13.12.1. Attached to an Air Force facility for medical care, the Air Force assumes

custody of their health records. When patients from other Services are treated in Air Force

facilities and require certain Service specific forms be completed and filed in the records,

the documents will be filed in their record. The documents will be placed in the appropriate

section of their outpatient record based on the type of form.

5.13.12.2. Treated in a MTF but their records are not available, send documents, routinely

included in Air Force outpatient records, to the custodian of their records. If unknown,

forward these documents using guidelines provided in appropriate subsections of

paragraph 5.19.

5.13.13. When Air Force personnel are treated at a United States Army or United States Navy

facility; send the documentation to the MTF where the record is maintained.

5.13.14. Interfile Army and Navy records with Air Force records. Replace folders with the

AF Form 2100A series only if the color and blocking do not permit interfiling.

5.13.15. Do not use the AF Form 2100A series to document or maintain Mental Health or

Family Advocacy notes, documents, or records. These files are separated from the outpatient

record and are secured in either the Mental Health Clinic or Family Advocacy Office.

5.14. Managing ARC Outpatient Records.

5.14.1. Health records for members of the AFR (Category A) and ANG or members of the

ARC who are on tours of active duty for less than 30 days are normally maintained with their

respective medical units, unless a local agreement or memorandum of understanding exists

between the MTF and the ARC unit(s) requires the MTF to maintain them.

5.14.1.1. The MTF may maintain health records for members of the AFR (Category A)

and ANG who have or are, a) placed on AD orders for more than 30 days; b) are currently

empaneled to a MTF Primary Care Manager; or c) the service member or unit has provided

AFMAN41-210 10 SEPTEMBER 2019 149

the MTF records department with the original health record and a copy of the member’s

activation orders. In these instances, the member is required to notify the MTF records

department upon completion or removal from AD and/or removal from active MTF

enrollment.

5.14.1.2. If the service member’s ARC unit does not provide the outpatient medical

records to the MTF during the ARC service member’s period of AD activation and/or

empanelment, the missing outpatient record will not negatively count against the MTF’s

paper records availability and accountability percentages.

5.14.2. Maintain separate paper-based health records for dual or multiple healthcare eligibility

patients, (e.g., a patient who is a family member husband and a RC service member) that have

already been created. Only maintain one electronic health record per dual eligible patient. See

Section 4B for additional guidance regarding dual or multiple eligibility patient record

maintenance. Medical and dental records for Category B (Individual Mobilization

Augmentee) and E (Participating Individual Ready Reserves) are maintained at the Individual

Mobilization Augmentee service member’s servicing MTF usually co-located at or near the

service member’s unit of attachment. Individual Mobilization Augmentee medical and dental

records will be maintained in accordance with the paragraph below. (T-3).

5.14.3. Maintain health records for Individual Mobilization Augmentees (Category B)

according to the following instructions:

5.14.3.1. Maintain records for centrally managed Individual Mobilization Augmentees

(HC, JA, and SG) with the AD MTF unit of attachment.

5.14.3.2. Maintain records of non-centrally managed Individual Mobilization Augmentees

with the AD MTF unit of assignment.

5.14.3.3. Complete an annual inventory of all ARC health records on file as of 31 March.

5.14.3.3.1. Readiness Management Group/Individual Reservist Medical Section

maintains a registry of Individual Mobilization Augmentee/Participating Individual

Ready Reserves records/locations, and can furnish a list of the records identified in

paragraph 5.14.3.1. Notify AFRC/Chief of Aerospace Medicine if records are not

located or if a records transfer (due to reassignment, retirement) is required.

5.14.3.3.2. The inventory will include:

5.14.3.3.2.1. Identify and remove Service Treatment Records of personnel no

longer assigned, or those who have retired or separated.

5.14.3.3.2.2. Identify records which are unaccounted, find or replace the records,

and take actions as required in AFI 41-200, paragraph 6.3.

5.14.3.3.2.3. Report summarized results of the inventory to the Executive

Management Committee.

5.15. Active Association and Geographically Separated Unit Outpatient Records

Management.

5.15.1. An Active Association is a construct which an AFR or ANG Sponsor Organization

shares a mission with one or more Regular Air Force Associate Organizations. The majority

of service members assigned to an Active Association and their family members will be

150 AFMAN41-210 10 SEPTEMBER 2019

enrolled in TRICARE Prime Remote. Similar to GSU, the nearest MTF will maintain the

official health records of Active Association members.

5.15.1.1. The nearest Air Force MTF commander or director and service member’s GSU

commander will ensure mechanisms are in place to access medical documentation

generated from civilian medical facilities and update the service member and family

member’s official health record.

5.15.1.2. For additional details on Active Association refer to AFI 90-1001, Planning

Total Force Association (TFAS) and for best practices AFMOA Health Benefits Kx page

at: https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

5.15.1.3. Personnel who are assigned to Active Associations will follow the same

guidelines as those assigned to Geographically Separated Units as outlined below this

section.

5.15.2. GSU personnel are AD service members, and their family members, assigned to a unit

with no on-site military medical support, and/or those who reside more than 50 miles or

approximately one hour of driving time from the nearest MTF.

5.15.3. In accordance with DoDI 6040.42, Medical Standards for Medical Coding of DoD

Health Records, all beneficiary medical records are the property of the DoD. Their

maintenance and availability are key to appropriate medical care and legal and administrative

proceedings. As such, the original health records of GSA service members and their family

members (if family members accompany the sponsor) will not be hand-carried or maintained

by the sponsor, the family members, or provided to the sponsor or family members’ civilian

Primary Care Manager Office. Alignment of Geographically Separated Unit s with MTFs for

medical records support will be based on proximity, past history, and Major Command

(MAJCOM) prerogatives. For tips and best practices see AFMOA Health Benefits Kx page at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

5.15.4. Affix the following statement to the outside of each original health record(s) using an

address label: “Assigned to an Active Association/GSA at or near (Enter City, State, Territory,

or Province name here). In accordance with AFMAN 41-210, Section 5B, DO NOT RETIRE

THIS OUTPATIENT RECORD.” See Figure 5.1 GSA Label.

5.15.5. Place a copy of the sponsor’s PCS orders in Section I of the health record on top of

most current DD Form 2766. Place a copy of the sponsor’s PCS orders in Section I of all

health records of family members identified on the PCS order to depart with the sponsor to the

Active Association/GSU. Forward these records to the appropriate MTF and inform the

sponsor which MTF will maintain their and their family members’ records. AD personnel and

their family members preparing to PCS to an Active Association/GSU may obtain, and hand-

carry, a complete copy of their records to these locations (to be obtained from the losing MTF

prior to departure). Members must request copies of their records no later than 30 days prior

to departure, to allow the MTF sufficient time to fill the request. (T-3). Place the copies in a

new AF Form 2100 Series record jacket. The record jacket of the copy should indicate the

record is a copy and identify the MTF where the official record is being maintained. See Figure

5.2 GSU Record Copy. When the members relocate to a non-remote location, upon in-

processing, they should notify the gaining MTF to request the records from the original losing

MTF.

AFMAN41-210 10 SEPTEMBER 2019 151

5.15.6. Exception for Sensitive Duties Program Participants: The original Service Treatment

Record of service members assigned to a GSU may be required to be maintained or stored at

the unit to maintain sensitive duties program participation. If the original Service Treatment

Record is required to be kept at the unit, the outpatient medical and dental records will be

maintained by the unit commander, and secured in a locked container behind at least one locked

door during non-duty hours. Access is restricted to the commander and the commander’s

designee for the Personnel Reliability Assurance Program, Presidential Support, and FLY

programs. A good example of this type of scenario would apply to service members assigned

to remote Munitions Sites (MUNS) GSU in USAFE-AFAFRICA. The nearest Air Force MTF

commander or director and service member’s GSU commander will ensure mechanisms are in

place to ensure all medical documentation generated from civilian medical facilities are added

into the service member’s Service Treatment Record and that all health records are maintained

in accordance with this manual. (T-3).

5.15.7. The MTF will educate the service members and family members on the process for

receiving medical and dental care at the new assignment. If the service members and family

members will be enrolled into TRICARE Prime Remote, educate beneficiaries on the

TRICARE Prime Remote program and assist with enrollment into the program.

5.15.8. When health record copies are provided, Air Force MTF records personnel will place

a “Property of the U.S. Air Force” label containing the appropriate MTF address on the record

jacket. (T-3). See Figure 5.2 GSU Record Copy.

5.15.9. Miscellaneous or loose medical documents generated by an MTF for Active

Association/GSU members and/or their family members will be scanned into Health Artifact

and Image Management Solution (HAIMS).

5.15.10. Upon reassignment from the Active Association/GSU to a military installation and

subsequent MTF Primary Care Manager assignment, the gaining MTF will send a DD Form

877 or DD Form 2138, so that the member’s original outpatient medical record(s) are

forwarded to the new location. Upon receipt of the original health record, cover the GSU label

with a blank label, create a new facility location label, and remove the PCS order to the

previous GSU location. The gaining MTF/Primary Care Manager shall complete a release of

information authorization for the patient to request copies of medical record documentation

from their civilian provider to be added into the official medical record. (T-3).

5.15.11. The MTF will educate the service members and family members on the process for

receiving medical and dental care at the new assignment. If the service members and family

members will be enrolled into TRICARE Prime Remote, educate beneficiaries on the

TRICARE Prime Remote program and assist with enrollment into the program.

152 AFMAN41-210 10 SEPTEMBER 2019

Figure 5.1. Sample GSU Label

Figure 5.2. Sample GSU Record Copy

5.16. Custody and Control of Health Records.

5.16.1. Beneficiary health records are the property of the United States Government. The

information contained in the record belongs to the patient. In accordance with the Privacy Act

of 1974 and HIPAA of 1996, the patient has the right to the information in the record.

However, the maintenance of the record at the MTF is a legal requirement. Refer to DoDI

6040.42. Agency obligations mandate the health records be available for continuity of care

purposes and to support national accreditation and DHA clinical coding auditing actions. The

lack of medical records and documentation may adversely impact individual patient medical

continuity of care as well as Joint Commission accreditation. Generally, beneficiaries are not

AFMAN41-210 10 SEPTEMBER 2019 153

authorized to hand-carry their health records in accordance with DHA policy and Air Force

policy identified in this manual. Local MTF records management policy must include

measures to (T-1):

5.16.1.1. Establish a methodology to obtain beneficiary medical record(s) upon arrival on-

station if hand-carried.

5.16.1.2. Establish custody of the health record upon the patient’s initial visit.

5.16.1.3. Ensure health records are available so that patients may obtain a copy of their

complete medical record. Refer to paragraph 4.4 for instructions on responding to patient

requests for copies of health records.

5.16.2. MTF personnel will not return an original medical or dental record to the patient’s

control after an outpatient visit unless authorized to do so by the MTF commander or director.

(Only on a case by case basis.) (T-3).

5.16.3. All miscellaneous, loose or late-flowing documents must contain sufficient patient

identification information to allow for proper scanning into HAIMS and or filing into paper

record when authorized in accordance with paragraph 5.12. (T-3). Additionally, these

documents must identify the outpatient records location and the MTF where the record is

maintained. (T-3).

5.16.4. Generally, borrowed records will be returned to the MTF record section by the end of

the day. However, records may be charged out or borrowed by an internal MTF requester for

up to five days if the record is needed to accomplish an official task, audit, review, etc. The

borrower must provide the rank (if applicable), first and last name, office symbol, name of

duty or work location, and telephone contact number. (T-3). The record must be returned to

the records library as soon as possible. (T-3). The records department supervisor may grant

extensions to the 5-day rule on a case-by-case basis. While in the borrower’s possession, the

record(s) must be secured and immediately produced upon request if required for patient care.

(T-3). When an extension is granted, “RE-CHARGE” the record to the borrower.

5.16.5. Service Treatment Record and Non-Service Treatment Record In-processing. Upon

receipt of each new Service Treatment Record not already maintained in the MTF records file

system, outpatient records personnel will perform a quality assurance inspection of the medical

record. (T-3). Inspection checks shall include the following, but are not limited to: a) ensure

the health record jacket is in satisfactory condition and labeled/documented properly, b) ensure

that medical documents are filed in their appropriate place, c) remove any misfiled wrong-

patient documents and forward the documents to the appropriate patient record or MTF, and

d) ensure Service Treatment Records contain the patients’ complete history of documented

healthcare (including all record volumes). (T-3). In the event a record is missing (i.e. received

Vol. 2 without Vol.1) the gaining MTF will contact the losing MTF to retrieve the missing

record. The losing MTF will mail the missing record as soon as possible but no later than five

days after request. (T-3).

5.16.6. As often as necessary, and whenever medical documents are filed into a health record,

records personnel will correct any obvious misfiles or other noticeable errors in each health

record. (T-3). MTFs should establish local guidance to best facilitate this process.

154 AFMAN41-210 10 SEPTEMBER 2019

5.16.7. Using Charge-Out Guides. Use AF Forms 885, 886, and 887 and AF Form 250, to

indicate the location of an outpatient record removed from the file. Use of the Medical Record

Tracking module in CHCS is required as a tool to track movement of outpatient records. (T-

3). It also enhances the management of records accountability and availability.

5.16.8. Authorized Exceptions that Allow Service Members to Hand-Carry Their Health

Records.

5.16.8.1. Every effort should be made to ensure patients do not leave the MTF with their

records unless authorized to do so. However, paragraph 5.30.1 and the two reasons below

indicate when MTF records managers are allowed to provide health records to

beneficiaries.

5.16.8.1.1. Exception #1. Applies to service members assigned to: Personnel

Reliability Assurance Program, Presidential Support Program, and overseas United

States embassy support. These members may also hand-carry their dental records. See

paragraph 5.28 for additional Personnel Reliability Assurance Program records transfer

instructions.

5.16.8.1.2. Exception #2. The MTF commander or director (Custodian of Records)

or delegate is authorized to grant exceptions (in writing) to this policy on a case-by-

case basis to satisfy unique individual situations where providing the original medical

and/or dental records to the requesting beneficiary is in the patient’s and/or the

government’s best interest. MTF commanders or directors may not issue general

blanket orders or MTF policy that allows any beneficiary to hand-carry medical or

dental records without careful analysis of all of the circumstances surrounding the

individual request. Additional exceptions may include circumstances in which a

significant inconvenience to the patient may occur or where continuity of care may be

negatively impacted if records were to be mailed. No sponsor is authorized to possess

or hand-carry the original health records or copies of health records for any member of

his family aged 18 years or older without written authorization from the family

member.

5.17. Filing Outpatient Computer Generated Clinical Diagnostic Results.

5.17.1. Daily filing of outpatient clinical diagnostic and/or test results is generally no longer

required. Diagnostic results and tests are easily obtained using available automated computer

system clinical diagnostic and test results retrieval mechanisms.

5.17.1.1. If there is a particular standard in the local community that requires the

maintenance of hard copy diagnostic test results or specifically prohibits the storage of

these results in electronic media, then the MTF must also comply. (T-0). Otherwise, there

is no requirement to print and file (into the paper outpatient medical record) a hardcopy

diagnostic or clinical test result.

5.17.1.2. Prior to any PCS reassignment, personal geographic location move, MTF

reassignment, or change to TRICARE enrollment location, MTF records personnel will

identify and print any CHCS laboratory, radiology, and/or clinical diagnostic results that

have accumulated from the departure or losing MTF for each departing beneficiary that are

not available in AHLTA due to age (i.e. prior to 2004/2005 depending on the

implementation date of AHLTA at the specific MTF). (T-2). This rule applies to Services

AFMAN41-210 10 SEPTEMBER 2019 155

Members, retirees, and family members alike. The losing MTF must still transfer the paper

record to the gaining MTF. (T-3). The gaining MTF will usually not be able to access or

view older clinical diagnostic reports and information completed and stored at another

MTF or on a CHCS host computer server other than their own. These procedures are

required to ensure the gaining MTF has access to the beneficiary’s complete health record.

5.18. Researching Appropriate Host MTF Record Locations.

5.18.1. Scan health record documents in the appropriate electronic health record as soon as

possible. The practice of blindly mailing medical documents or records to the MTF closest to

where the beneficiary lives or works is prohibited. (T-1). Confirmation of the exact MTF

responsible for maintaining the beneficiary’s health record(s) is required. If confirmation

cannot be obtained, then contact the specific Uniformed Service personnel office according to

the instructions in the following sections.

5.18.2. AD Service Members: AD service members may incur several PCS assignments;

same station - Permanent Change of Assignment (PCA) relocations; TDY, deployments, and

personal Leave absences that may include travel to various locations throughout the United

States and abroad. Along the way, MTF medical records personnel may receive medical

documents from internal facility clinics for AD patients who have received transient medical

care during these periods. Whatever the reason, the process of tracking down and locating

current duty assignment stations is sometimes challenging. Several options for locating the

primary record custody locations are listed below.

5.18.2.1. Primary AD Research Methods: Locate a patient’s primary record location by

accessing the CHCS-DEERS eligibility menu option or by referencing the General Inquiry

of DEERS Internet website at https://www.dmdc.osd.mil/opsconnect/. Defense Medical

Information System Identification location, military installation name, and current patient

address are listed. Sponsor Social security number is required to complete search. User

Identification and personal password are required to access this website application.

Contact the Site Security Manager (SSM) to obtain necessary access. Contact

AFMOA/SGAT if the Site Security manager is not known.

5.18.2.2. Alternate Methods:

5.18.2.2.1. When researching Air Force service member, access the Air Force Portal

website’s “White Pages” locator at https://www.my.af.mil/. User Identification and

personal password are required. Additionally, the Air Force Global e-mail directory

may be used as another alternative reference method.

5.18.2.2.2. Although not a medical records or MTF locator, the DefenseLink Internet

website at http://www.defenselink.mil/faq/pis/PC04MLTR.html may be of some

limited use when researching an individual service member’s duty address or duty

contact information.

5.18.3. Family Members, Retired Military Members, and Other Non-Military Personnel:

Health records of Air Force AD family members are usually maintained at the MTF where the

sponsor is assigned unless the sponsor is stationed at a remote or unaccompanied tour

assignment. File medical documents for family members of AD or retired military in the

medical record at the MTF where the majority of care is provided or where the dependents are

156 AFMAN41-210 10 SEPTEMBER 2019

empaneled or enrolled in TRICARE. If the medical document(s) do not belong at the MTF

where the research is accomplished, follow the instructions below.

5.18.3.1. Research Methods for Family Members, Retired Military Members, and Other

Non-Military Personnel: Locate a patient’s primary record location by accessing the

CHCS-DEERS eligibility menu option or by referencing the General Inquiry of DEERS

Internet website at https://www.dmdc.osd.mil/opsconnect/. Defense Medical

Information System Identification location, military installation name, and current patient

address are listed. Sponsor Social security number is required to complete search. User

Identification and personal password are required to access this website application.

Contact the SSM to obtain necessary access. Contact AFMOA/SGAT if the Site Security

Manager is not known.

5.18.3.2. In all other cases where the record cannot be located use the patient’s

identification to scan the documents into the approved electronic health record.

5.18.4. If patient cannot be properly identified, return document(s) to the originating clinic for

required identification data completion.

5.18.5. Develop local procedures between clinic and ancillary services personnel to correct

errors and avoid omissions. Do not ask the patient to return an improperly completed form to

the originator.

5.18.6. If the referring clinic cannot sufficiently identify the documents for filing/scanning,

contact the Medical Record Review Committee chairperson or the Chief of Medical Staff. If

after an extensive review the documents in questions cannot be identified by name, Social

security number, date of birth, or by any other available means, the Record Review Committee,

with approval from the Chief of Medical Staff, may destroy unidentifiable health documents.

5.19. Loose Leaf, Orphaned, or Miscellaneous Medical Documents.

5.19.1. Health record documents, separated from the primary health record will follow the

HAIMS guidance referenced in paragraph 5.4.10.2.1.

5.19.1.1. AD Air Force Personnel. Locate a patient’s primary record location by accessing

the CHCS-DEERS eligibility menu option or by referencing the General Inquiry of DEERS

Internet website at https://www.dmdc.osd.mil/opsconnect/. Follow the same instructions

as listed in paragraph 5.18.2.1. If there is not enough patient data listed on the form(s) to

properly identify the patient, then submit the documents to the MTF Health Records

Committee. The committee is authorized to order the destruction of unidentifiable medical

documents. Do not send loose or unidentifiable medical documents to the AFPC Service

Treatment Record disposition center or to the AFPC world-wide personnel locator office.

5.19.1.2. AFR Personnel. Although the CHCS-DEERS eligibility menu option or the

General Inquiry of DEERS Internet website may not identify the service member’s AFR

location, it may identify the individual’s home address, unit Personnel Accounting Symbol

Code, and/or last known AD Defense Medical Information System Identification location

(if the service member was activated at some point in the recent past). Follow the same

instructions as listed in paragraph 5.18.2.1. If unable to locate member’s primary records

custody location, or if there isn’t enough patient data listed on the form(s) to properly

identify the patient, and/or the service member’s unit, contact the AFRC Command

AFMAN41-210 10 SEPTEMBER 2019 157

Surgeon’s Office, Robbins Air Force Base, Georgia (GA) for additional guidance. Do not

forward medical documents to AFRC without prior approval from an AFRC official.

Furthermore, do not forward dependent or retiree health records or loose/orphaned

documents to AFRC, nor to any AFR unit as they do not maintain records for retirees or

dependents.

5.19.1.3. ANG Personnel. Although the CHCS-DEERS eligibility menu option or the

General Inquiry of DEERS Internet website may not identify the service member’s Guard

Medical Unit location, it may identify the individual’s home address, unit Personnel

Accounting Symbol Code, and/or last known AD Defense Medical Information System

Identification location (if the service member was activated at some point in the recent

past). Follow the same instructions as listed in paragraph 5.18.2.1. If unable to locate

member’s primary records custody location, or if there isn’t enough patient data listed on

the form(s) to properly identify the patient and/or member’s unit, contact Office of the Air

Surgeon (NGB/Chief of Aerospace Medicine), NGB, Joint Base Andrews, Maryland, for

additional guidance. Do not forward medical documents to NGB without prior approval

from a NGB official. Furthermore, do not forward dependent or retiree health records or

loose/orphaned documents to this HQ command, nor to any ANG Unit as they do not

maintain records for retirees or dependents.

5.19.1.4. United States Air Force Individual Mobilization Augmentee Personnel. Locate

a patient’s primary record location by accessing the CHCS-DEERS eligibility menu option

or by referencing the General Inquiry of DEERS Internet website at

https://www.dmdc.osd.mil/opsconnect/. Follow the same instructions as listed in

paragraph 5.18.2.1. If unable to locate member’s primary records custody location, or if

there isn’t enough patient data listed on the form(s) to properly identify the patient, and/or

Individual Mobilization Augmentee’s unit of attachment, contact Readiness Management

Group/Individual Reservist Medical Section, Warner Robins Air Force Base, Georgia, for

additional guidance. Do not forward medical documents to AFRC without prior approval

from an AFRC official. Do not forward dependent family member or retiree service

member health records to this command.

5.19.1.5. United States Army Personnel. Forward United States Army health records or

document(s) according to the instructions listed below:

5.19.1.5.1. Locate a patient’s Primary Care Manager and primary record location by

referencing the General Inquiry of DEERS Internet website at

https://www.dmdc.osd.mil/opsconnect/. Defense Medical Information System

Identification location, military installation name, and current patient address are listed.

Follow the same instructions as listed in paragraph 5.18.2.1. If unable to locate

member’s primary records custody location, forward AD officer, warrant officer, and

enlisted health records to:

AMEDD Record Processing Center

3370 Nacogdoches Road, Suite 116

San Antonio, TX 78217

5.19.1.6. United States Navy Personnel. Forward United States Navy health records or

document(s) according to the instructions listed below.

158 AFMAN41-210 10 SEPTEMBER 2019

5.19.1.6.1. Locate a patient’s primary record location by accessing the CHCS-DEERS

eligibility menu option or by referencing the General Inquiry of DEERS System

Internet website at https://www.dmdc.osd.mil/opsconnect/. Defense Medical

Information System Identification location, military installation name, and current

patient address are listed. Follow the same instructions as listed in paragraph 5.18.2.1.

If unable to locate member’s primary records custody location, then draft and forward

a generic letter with the name and Social security number of the AD, Reserve, or retiree

to the Department of the Navy, Navy Personnel Command (NPC), PERS-312, 5720

Integrity Drive, Millington, TN 38055-3120, commercial voice contact at (901) 874-

3388, DSN Voice at 882-3388, or FAX to DSN 882-2766. The NPC should provide

advice as to whether the document(s) and/or record(s) should be retired to National

Personnel Records Center or to the VA Records Management Center. For more

information, visit the United States Navy Personnel Command website at

http://www.npc.navy.mil/.

5.19.1.7. United States Marine Corps Personnel. Forward United States Marine Corps

health records or document(s) according to the instructions listed below.

5.19.1.7.1. Locate a patient’s primary record location by accessing the CHCS-DEERS

eligibility menu option or by referencing the General Inquiry of DEERS Internet

website at https://www.dmdc.osd.mil/opsconnect/. Defense Medical Information

System Identification location, military installation name, and current patient address

are listed. Follow the same instructions as listed in paragraph 5.18.2.1. If unable to

locate the member’s primary records custody location, forward the medical record(s)

or form(s) to the United States Marine Corps (USMS) Worldwide Locator Service,

Commandant of the Marine Corps, Headquarters USMC, Code MMSB-10, Quantico,

VA 22134-5030.

5.19.1.8. United States Coast Guard. Locate a patient’s primary record location by

accessing the CHCS-DEERS eligibility menu option or by referencing the General Inquiry

of DEERS) Internet website at https://www.dmdc.osd.mil/opsconnect/. Defense Medical

Information System Identification location, military installation name, and current patient

address are listed.

5.19.1.9. United States Public Health Service Commissioned Corps records or documents

with a complete name and social security number should be forwarded to the Office of

Commissioned Corps Support Services, Medical Branch, 5600 Fishers Lane, Parklawn

Building, Room 4C-04, Rockville, MD 20857-0435.

5.19.1.10. National Oceanic and Atmospheric Administration records or documents with

a complete name and social security number, should be forwarded to:

U.S. Public Health Service

Commissioned Personnel Center

Attn: CDR Hobson-Powell

National Oceanic and Atmospheric Administration

8403 Colesville Road, Suite 500

Silver Spring, Maryland 20910.

AFMAN41-210 10 SEPTEMBER 2019 159

5.19.1.11. Retired Military and Family Members. Locate a patient’s primary record

location by accessing the CHCS-DEERS eligibility menu option or by referencing the

General Inquiry of DEERS Internet Website at https://www.dmdc.osd.mil/opsconnect/.

Defense Medical Information System Identification location, military installation name,

and current sponsor/patient address are listed. Sponsor’s social security number is

required. If unable to locate the family member’s Primary Care Manager and/or primary

records custody location, place the loose documents in a charge-out guide and follow

instructions listed in paragraph 5.18.3.1.

5.19.2. Remember to identify the primary health records custody location Identification for all

patient categories, in all services. First try the CHCS-DEERS System eligibility menu option,

then reference the General Inquiry of m Internet Website at:

https://www.dmdc.osd.mil/opsconnect/. Finally, be sure to follow the individual Uniformed

Services forwarding instructions or contact the agency in question before mailing the

documents via the United States Postal System.

5.19.3. If the gaining/servicing MTF cannot be clearly identified, do not mail the medical

documents or record. Mailing medical documents or records to the MTF closest to where the

beneficiary lives or works is prohibited. Confirmation of the exact MTF responsible for

maintaining the beneficiary’s health record(s) is required. The losing MTF must maintain the

record until it is requested or eligible for retirement to National Personnel Records Center. (T-

3).

5.19.3.1. National Personnel Records Center. For loose documents belonging in records

stored at National Personnel Records Center and those recalled from National Personnel

Records Center.

5.19.3.2. When loose documents are identified but the original medical record has already

been transferred to the National Personnel Records Center, then:

5.19.3.2.1. Place documents in a folder (manila folder is acceptable).

5.19.3.2.2. Label the folder with the patient identifiers using a standard CHCS label to

include at a minimum; last name and first name, sponsor social security number, patient

date of birth, and record volume number (e.g., volume 2). Note: the label can be

handwritten vs. CHCS output.

5.19.3.3. Add the record to the retirement index (via CHCS) for transfer to National

Personnel Records Center in accordance with the disposition rules in AFRIMS.

5.19.3.4. Do not mail or return recalled records to National Personnel Records Center

directly. Recalled records must be created within CHCS as a new volume and retired when

eligible in the MTF’s next scheduled retirement. (T-3).

5.20. Missing and Lost Health Records.

5.20.1. Health records, both in electronic and paper form are considered PHI and Personally

Identifiable Information subject to HIPAA and the provisions of the Privacy Act. Once a health

record is deemed “lost,” specific steps must be taken in order to report the information and

notify the affected beneficiary or party. (T-3).

5.20.2. There are several instances when a health record may be considered “missing.” Some

of the most common examples are:

160 AFMAN41-210 10 SEPTEMBER 2019

5.20.2.1. A health record may be considered “missing” immediately following a record

room supervisor’s investigation of the circumstances surrounding the record’s

disappearance.

5.20.2.2. When a health record is discovered missing from the main Record File with no

documented borrower location or date.

5.20.2.3. When a record is discovered missing from the main Record File with a

documented borrower location and date, but the physical record has not returned to the

Main File following a period of 30 calendar days or more - without a documented

explanation.

5.20.3. MTFs must exhaust all reasonable means to locate a missing health record. (T-1).

When records are discovered to be missing, each MTF staff member is responsible for

searching their immediate work area(s). MTF personnel will mobilize and help search for a

missing record.

5.20.3.1. The following procedures are required after discovering a record is missing:

Check to identify possible borrower charge-out locations in the automated Medical Record

Tracking module; check for record misfiles in each record storage room; search provider

offices and exam rooms; ensure the record has not been forwarded to a peer review or

clinical review committee, meeting, or function; verify the record has not been sequestered

from main file; verify the record has not been temporarily separated from the main file for

any other official review function; if known, contact the previous MTF responsible for

maintaining the beneficiary’s health records; contact the service member/beneficiary to see

if the member/beneficiary is in possession of the record. (T-1). If the record still has not

been located following the preceding minimum search requirements, begin processing the

Non-Availability Letter for Service Treatment Records and breach notifications. In

addition, the MTF Verification Checklist must be completed in accordance with paragraph

5.7.5.4. (T-0).

5.20.3.2. After all efforts to find the lost health record(s) are exhausted the MTF

commander or director may deem the missing health record as “lost.” Once the MTF

commander or director has deemed a record “lost,” MTF HIPAA privacy officer must

follow the guidelines and procedures identified in AFI 41-200, paragraph 6.5., in

consultation with the installation public affairs officer, as applicable and available

installation legal staff and/or the medical law consultant. (T-0).

5.21. Health Records Availability, Accountability, and “Tracking” Standards.

5.21.1. All MTFs and/or medical units with CHCS computer capabilities must utilize the

CHCS Medical Record Tracking function to properly manage, track, and locate health records.

(T-1). Efficient use of associated Medical Record Tracking system tools like the records bar

code scanner and electronic AF Form 250 will save time and reduce misplaced paper health

records. Any non-MTF organization authorized to maintain AD service member or RC health

records without using the CHCS computer Medical Record Tracking module to identify and

manage their record inventory, shall establish a manual tracking system. (T-1).

5.21.2. The CHCS computer Medical Record Tracking function will be used to charge in and

charge out records between the medical records department and every authorized requesting

borrower location in the MTF or within the medical unit. (T-1). Records managers should

AFMAN41-210 10 SEPTEMBER 2019 161

create or build borrowing locations within the Medical Record Tracking module for all

locations/borrowers that regularly request health records. Contact the site CHCS systems

office for assistance.

5.21.3. Monthly Outpatient Medical Record Accountability Review: Every 30 days, records

managers in each MTF record room will review all of the medical records that have been

loaned or charged out to borrowers for more than 5 days. (T-1). Records personnel are required

to identify each overdue record and contact the last known borrower to inquire about the status

of the record. (T-1). Establish a local process to retrieve records that have been loaned to

borrowers for more than 5 days. Overdue records will be identified by viewing the CHCS

Overdue Records List Report or similar CHCS records management reporting mechanism. (T-

1). Maintain monthly overdue/missing record statistics by documenting the overall records

assigned to the individual record room (denominator) and comparing this number to the

number of overall missing and/or overdue medical records (numerator). To obtain the

percentage of missing and/or overdue records, divide the numerator by the denominator.

Report findings monthly to the Health Record Review Committee (or similar records review

function), and to the TRICARE Operations and Patient Administration Flight Commander or

Patient Administration Officer. The TRICARE Operations and Patient Administration

function is responsible for creating an aggregate MTF total of overdue or missing records. The

TRICARE Operations and Patient Administration Flight Commander or Patient

Administration Officer will use the submitted information to identify duty locations and/or

individuals who routinely borrow records without returning them to the main file. (T-1). Refer

to paragraph 5.14 for potential medical records availability exceptions for RC service members

on AD orders. Refer to paragraph 5.20., lost medical records, for additional information

regarding obligations required when reporting missing or lost medical records.

5.21.4. Health Record Availability Standards: With the implementation of the DoD electronic

health record, immediate reliance upon outpatient paper medical records should diminish, not

cease. Eventually, the AFMS will completely transition from a paper-based to a

comprehensive, all-inclusive, electronic health record system. However, to satisfy DoD, Joint

Commission, and functional and provider point-of-service outpatient medical record

availability, and various auditing requirements, paper outpatient paper medical records must

still be maintained and accounted for at each MTF. (T-1). The two basic medical records

availability metrics standards outlined below measure a MTF’s compliance.

5.21.4.1. Service Provider Point of Service Record Availability Standard. Unless a MTF

has implemented a local policy to retrieve or pull outpatient paper medical records by

exception, MTFs will continue to implement a system to meet the minimum 95% (goal is

100 percent) AFMS provider point-of-service availability standard. (T-1). AFMS Provider

Point of Service availability is defined as the physical presence of the paper record for use

at the point-of-service or when needed for specific review or audit. This standard applies

to MTF records rooms (whether centralized or decentralized).

5.21.4.1.1. Methodology. Outpatient records availability percentages are generated by

tracking and maintaining the numbers of records that were retrieved and delivered to

the point-of-service, then dividing by the number of record requests (manual entry AF

Form 250 and electronic record requests) received. The overall monthly MTF records

availability percentage is generated by combining the monthly number of records

delivered to the point-of-service (for each individual records room) then dividing this

162 AFMAN41-210 10 SEPTEMBER 2019

total number by the total number of all MTF outpatient record room requests (manual

and electronic). Report this data to the MTF Health Record Review Committee or

function and to the AFMOA/SGAT office by the 10th duty day following the close of

the previous reporting month.

5.21.4.1.2. For patients with multiple appointments on the same day, count the record

as being available for all of the appointments as long as the record(s) was delivered to

the first scheduled appointment. However, records personnel should attach a note or

locally created notice or flag to the record, before distribution to the first appointment

location. The note should inform the record(s) borrower that the patient has multiple

same-day appointments. The note or flag will alert clinic staff to forward the patient’s

record to the next clinic. Clinic personnel are required to forward the record to the next

location.

5.21.4.2. DoD Minimum Functional Control Record Availability Standard. MTF records

managers must ensure their outpatient records control process include procedures to ensure

95% percent availability of all outpatient medical records. (T-1). Availability is defined

as any outpatient medical record located within the MTF having functional responsibility

for maintaining the record. DoD availability is not to be confused with provider or point

of service availability as described in the previous paragraph.

5.21.4.2.1. Methodology. DoDI 6040.40, Military Health System Data Quality

Management Control Procedures, Enclosure 1, paragraph C.6., identifies a minimum

on hand records availability audit formula. From a random sample of CHCS outpatient

appointments from the reporting month, medical record personnel will determine the

percentage of available or on hand outpatient paper medical records that can be

physically located in a record room file system. If an outpatient record is not

immediately physically available in the record room file, but a properly documented

AF Form 250 and plastic record charge-out guide are filed in place of the paper record,

then count the record as available.

5.21.4.2.2. If a MTF can prove record availability, according to this standard, by

pinpointing the specific location of the record within a MTF medical records

department(s) or MTF borrower location, using the CHCS computer Medical Record

Tracking module or from a properly documented AF Form 250, then count the record

as available. Records loaned to a borrower with a check-out date older than 30 days,

must be physically located and verified with the borrower. (T-1).

5.21.4.3. Report monthly AFMS availability and Office of the ASD for Health Affairs

availability percentages to the MTF Health Record Review Committee. The committee

chairperson will report this information monthly to the Executive Committee of the

Medical Staff unless otherwise directed by the MTF commander or director. (T-1).

5.21.4.4. Refer to paragraph 5.14 for potential records availability exceptions for RC

service members placed on AD.

5.21.5. Converting to a Paper Medical Records Retrieval or by Exception Process: The Health

Record Review Committee and the Executive Committee must support any decision to suspend

or discontinue retrieving or pulling outpatient medical records for daily outpatient

appointments. (T-3).

AFMAN41-210 10 SEPTEMBER 2019 163

5.21.5.1. The MTF Chief of Medical Staff, in coordination with the unit commander(s) are

responsible for health records maintenance and management, must determine, based on

program management analysis and input from the entire clinical staff that all providers who

use AHLTA, are using the system the way it was designed to be used. (T-2).

5.21.5.2. If the Chief of Medical Staff and respective unit commander(s) support the

decision to suspend daily paper outpatient medical records retrieval and distribution, the

MTF commander or director may approve the decision or determine another course of

action. Approval may be for defined specialty groups, Family Health Elements, clinics

and/or entire facilities. Documentation of approval must include any sub-groups that will

continue to require paper records on a regular basis. (T-3).

5.21.5.3. Prior to approving any retrieve or pull records by exception policy, the MTF

commander or director must ensure that the requesting clinical work center(s) have created

a process to verify patients have signed the MHS Notice of Privacy Practices for each

empaneled patient. (T-0). Refer to AFI 41-200, paragraph 3.2 for specific information and

expectations regarding HIPAA (MHS Notice of Privacy Practices requirements.

5.21.5.4. If the MTF commander or director decides to suspend traditional daily paper

outpatient medical records retrieval and distribution processes, an immediate six-month

trial phase will begin starting from the date of the decision or other designated

implementation date.

5.21.5.5. During this period, the AFMS Provider or Point of Service records availability

percentage, for patients with a) an established electronic medical record history, b) new

patients with no previous outpatient paper medical record, and c) patient encounters for

which the provider does not need to reference the traditional paper outpatient medical

record, will be deemed to be 100%. Records room managers will meet with the CHCS site

manager and/or information systems managers to suspend the automated function that

produces the pre-printed AF Form 250, prior to each patient’s appointment. Records

personnel will inform clinic staff that individual records requests are still possible using

CHCS.

5.21.5.6. During this period, if a provider(s) requests the traditional paper outpatient

medical record prior to a patient encounter, and assuming there is an established traditional

paper record on file, records room personnel will retrieve and distribute the requested

record(s). For all requested traditional outpatient paper medical records requested

separately from the AHLTA system, records room supervisors will apply the same record

availability methodology previously referenced in paragraph 5.21.5.1., and report this

records availability statistic monthly to the Health Record Review Committee and to

AFMOA/SGAT. (T-1).

5.21.5.7. After the six-month trial phase, the chief of medical stall will coordinate options

with the unit commander responsible for health records. Also, the chief of medical staff

will receive input from the Health Record Review Committee, the Executive Committee

of the Medical Staff and the provider staff. After these coordination efforts, the chief of

medical staff will recommend one of the following option to the MTF commander or

director:

164 AFMAN41-210 10 SEPTEMBER 2019

5.21.5.7.1. Permanently or temporarily cease MTF daily outpatient paper medical

records retrieval and distribution processes,

5.21.5.7.2. Implement a limited cessation or selective cessation (based on MTF-unique

circumstances) of paper medical records retrieval and distribution,

5.21.5.7.3. Institute another trial period, or

5.21.5.7.4. Determine some other appropriate action. Additionally, whatever process

is chosen, paper documents from internal and external sources will be scanned and

uploaded into Health Artifact and Image Management Solution (HAIMS) or the

approved electronic health record. (T-1).

5.21.5.7.5. Exception: For official auditing purposes, the MTF must either supply the

auditor with a paper copy of the applicable patient encounters, or provided access to

AHLTA to review the outpatient encounter documentation. (T-3).

5.21.6. Using Charge-Out Guides. Use AF Forms 885, 886, and 887 and AF Form 250, to

indicate the location of an outpatient record removed from the file. Use of the Medical Record

Tracking module in CHCS is required as a tool to track movement of outpatient records. It

also enhances the management of records accountability and availability.

5.21.7. Loaning Records to Clinics/Units. MTFs must establish strict, but sensible,

procedures to manage the loaning of records. (T-3). The following instructions must be

adhered to ensure sound health records management operations (T-3):

5.21.7.1. Limit access to all outpatient medical records areas to only authorized personnel.

MTF personnel should not be granted access based solely on the proximity of their clinic

or work center to the secure records area.

5.21.7.2. When a paper medical record is requested or removed from file by an authorized

borrower, records room personnel will ensure the borrower uses a charge-out guide and

completes the AF Form 250 with accurate, adequate, and legible, information or requests

the record through the CHCS Medical Record Tracking module. Whenever possible,

automated CHCS AF Form 250s should be used to place inside the charge-out guide.

5.21.7.3. The outpatient records department and clinic personnel will ensure the outpatient

record is available prior to the patient’s appointment.

5.21.7.4. Medical records staff must notify the requesting clinic or clinical work center

when the medical record is not available. If the record is not available at the clinic or

borrower’s location before the patient arrives the clinic staff should access the Medical

Record Tracking module to locate the health record(s) or contact the medical records

department if an explanation has not been provided. If the record is not available, the

provider should make an entry on the form used to document care that the record was not

available for review.

5.21.7.5. Generally, health records are only to be loaned to internal work centers.

However, there may be very unique instances when the original health record(s) may be

released to an outside agency, MTF, civilian medical facility, or even the patient. The MTF

commander or director is the only official authorized to release original health record(s) to

external MTF requestors. Note: If a health record(s) is involved in a potential Medical

Affirmative (MAC) Claim, or other potential claim either for or against the United States

AFMAN41-210 10 SEPTEMBER 2019 165

Government, or for potential litigation, or for use as evidence in a court of law, do not give

the original record to the patient. All parties with legitimate and legal authorization to

receive either the health record(s) or copies will be provided the information once all

security validation and/or authorization requirements have been met. Refer to AFI 41-200,

paragraphs 4.1.-4.3., Use and Disclosure of PHI, for further guidance.

5.21.7.5.1. The Medical Cost Reimbursement Program (MCRP) replaced the Hospital

Recovery (HR) claims program administered by base legal offices and is now

administered through 8 regional offices. Medical Cost Reimbursement Program

recoveries are made pursuant to the Federal Medical Care Recovery Act and the

Coordination of Benefits statute, as well as any applicable state laws allowing for

recovery.

5.21.7.5.2. All money recovered will be returned to the MTFs or DHA. Medical Cost

Reimbursement Program legal personnel may require access to health records and

MTFs should coordinate the appropriate access to needed health information. For more

information on Medical Cost Reimbursement Program, contact the Air Force Legal

Operations Agency, Claims and Tort Litigation Division (AFLOA/JACC).

5.21.7.6. Health records for military retired service members and the records of a retired

service member’s family members must be maintained at a MTF. (T-1).

5.21.8. Medical Records Custody Responsibility and Records Borrower Training.

5.21.8.1. TRICARE Operations and/or Patient Administration officials will brief newly

assigned staff members during initial in-processing or MTF newcomer’s orientation and

again annually thereafter, about their responsibilities regarding expected health records

custody management. (T-1). Training should provide, but not be limited to, how to request

a paper medical record, information regarding appropriate records control, release,

availability, accountability of health records, and the transition from paper-based to

electronic health records. Training may be informal, formal, or computer-based. This

records awareness training is separate from initial and annual HIPAA training requirements

outlined in AFI 41-200.

5.21.8.2. Training will be documented in the Career Field Education and Training Plan or

other official record of personnel training accomplishments. (T-1).

5.21.8.3. Just as important as the availability of health records so is the completeness of

the documentation for the same. MTFs will establish procedures to ensure that records

contain accurate and complete documentation of outpatient visits. (T-1).

5.21.8.4. MTFs should inform beneficiaries of DoD and AFMS health records custody

rules whenever and wherever possible (e.g., at town hall meetings, via patient newsletters,

time of MTF registration, etc.).

5.21.9. Obtaining Government Owned Medical Record(s) from Patients: When it is known

that a patient has custody of their record(s), initiate the following procedures to retrieve the

record from the patient:

5.21.9.1. Contact the patient and/or the sponsor and inform the party(s) the record(s) is the

property of the United States Government and must be returned immediately. (T-3).

166 AFMAN41-210 10 SEPTEMBER 2019

Inform the patient they may receive a free copy of the record but the original must be

maintained at the MTF. (T-3).

5.21.9.2. If the patient does not return the record after contact, take the following actions:

5.21.9.2.1. AD and their Family Members: Contact the sponsor’s first sergeant or unit

commander for assistance in retrieving the health record(s). Inform the sponsor’s unit

commander or first sergeant of the previous attempts to collect the record(s) in

accordance with this manual. If, after contacting the sponsor’s chain of command, the

patient still has not returned the record(s), send a certified letter to the sponsor’s and/or

patient’s home address notifying the sponsor and/or patient that the record(s) are the

property of the United States Government. Inform the sponsor or patient that a

complete copy may be provided at no charge, but that a signed authorization is required

to obtain the record of any dependent authorized to consent for their own care.

Reference any known previous attempts or actions to collect the record(s) and instances

(if any) of refusals to cooperate. Request the record(s) be returned to the MTF within

10 calendar days from receipt of the letter. Inform the sponsor that failure to comply

will result in an additional notification to the first sergeant or unit commander which

may result in potential administrative or corrective personnel action.

5.21.9.2.2. For all other beneficiaries enrolled to the MTF: If, after requesting the

record(s) in accordance with the directions found in this manual, the patient(s) still has

not returned the record(s), send a certified letter to the sponsor’s and/or patient’s home

address notifying that the record(s) are the property of the United States Government.

Inform the sponsor or patient, that a complete copy may be provided (at no charge) to

the sponsor and/or patient. Reference any known previous attempts or actions to collect

the record(s) and instances (if any) of refusals to cooperate. Request the record(s) be

returned to the MTF within 10 calendar days from receipt of the letter. Inform the

patient and/or sponsor that failure to comply will result in notification to local law

enforcement or installation Security Forces which may result in a criminal investigation

for theft of United States Government property.

5.21.10. Clinic Personnel Record Accountability and Tracking Responsibilities:

5.21.10.1. Clinic personnel must keep outpatient record entries up-to-date and use the

following disposition rules (T-3):

5.21.10.1.1. As a general rule, records are to be returned to the Outpatient Records

location at the end of the duty day associated with each episode of care. Any provider

requiring extended use of a record to complete necessary healthcare documentation

requirements should re-charge the health record to their clinic every three-days using

the CHCS Medical Records Tracking module.

5.21.10.1.2. Admission to Hospital. Send the outpatient record to the designated

inpatient nursing unit. Clinic personnel will update the CHCS Medical Record

Tracking module to document that the record has been transferred to the appropriate

inpatient nursing unit

5.21.10.1.3. Transfer of Patient to Another Military Facility for Treatment. Outpatient

medical records may be transferred to another MTF without obtaining a patient’s

AFMAN41-210 10 SEPTEMBER 2019 167

permission. MTF personnel are required to document the record transfer using the

CHCS Medical Record Tracking module.

5.22. Medical Documentation Requirements for Partial Hospitalization.

5.22.1. Partial hospitalization is defined as a facility or unit that provides a planned therapeutic

program for patients who do not require full time hospitalization, but who need broader

programs than are possible from outpatient visits in a hospital-based or hospital-affiliated

facility. Patients would spend a portion or majority of a day (less than 24-hour daily care) in

a hospital setting and then return to their homes or places of residence in the evening. They

would then return to the facility on the following day.

5.22.1.1. Partial hospitalizations are characterized by structured, daily supervised,

outpatient activities over a prolonged period (usually 2-6 weeks) tailored to treat or

rehabilitate individuals with generic-like illnesses, dependencies or psychological profiles.

Partial hospitalization may be used for crisis stabilization, treatment of partially stabilized

mental health disorders for adults and adolescents, chemical dependency treatment

programs, or as a transition from an inpatient program when medically necessary.

5.22.1.2. All documentation for partial hospitalization must comply with the current Joint

Commission documentation standards. (T-1). SFs, or other forms, as noted, are

recommended for use in the partial hospitalization records. At a minimum, the

documentation in the medical record will include (T-1):

5.22.1.2.1. SF 504, Clinical Record-History Parts I and II.

5.22.1.2.2. SF 505, Clinical Record-History Parts II and III.

5.22.1.2.3. SF 506, Clinical Record-Physical Examination.

5.22.1.2.4. Nursing assessments and interventions.

5.22.1.2.5. SF 509, Medical Record – Progress Notes written daily, which reflects a

brief summary of the therapeutic activity, observation of the patient’s status and

responses in the course of the therapeutic contact and the therapist’s plans for any

subsequent therapeutic contact.

5.22.1.2.6. AF Form 3066 or 3066-1.

5.22.1.2.7. AF Form 3069, Medication Administration Record as applicable.

5.22.1.2.8. Supporting documentation such as case management notes, treatment team

notes, weekly progress summaries, and physician summaries including physician

supervision, evaluation, and certification.

5.22.1.2.9. Patient education, release instructions, and plans for follow-up care.

5.22.1.3. All documentation related to a partial hospitalization stay will be filed as a

package in the mental health record in accordance with AFI 44-172, in Section III of the

outpatient medical record, or scanned and uploaded into HAIMS as applicable. (T-1).

Illnesses related to mental health will be filed in the mental health record. (T-1).

168 AFMAN41-210 10 SEPTEMBER 2019

5.23. Supplemental Documentation Guidance.

5.23.1. Inpatients Seen in Outpatient Clinics. Occasionally, inpatients may have appointments

in an outpatient clinic during their admission. After the appointment, the outpatient clinic staff

will forward the outpatient appointment document(s) to the inpatient’s nursing unit or place

into the inpatient medical record.

5.23.2. Withdrawing Documents. When documents in an outpatient record are relevant to

further treatment as an inpatient, the documents may be withdrawn and inserted in the inpatient

record. Note the withdrawal on SF 600. Other than this exception, original medical

document(s) will not be removed from a medical record after filing.

5.23.3. Dead on Arrival and Emergency Room (ER) Death. All MTF Dead on Arrival and

ER Death encounters will be reported in the automated ambulatory data collection system or

other ambulatory data collection and coding system. Appropriate clinical coding and Medical

Expense and Performance Reporting System code assignment is required. Any documents

created for these patients will be filed in an extended ambulatory record and maintained in a

secure, limited access area, separate from inpatient/outpatient health records. (T-3).

5.23.4. Variations in the disposition and maintenance of records in clinics are not authorized.

The MTF commander or director ensures that the health records are maintained as required by

current Air Force directives.

5.23.5. Request for Ancillary Services. Clinic personnel will ensure the appropriate ancillary

request form is properly completed and lists all patient identification and other data required

by directives. (T-3). Develop local procedures between clinic and ancillary services to correct

errors and avoid omissions.

5.23.6. When health record documents are received without adequate identification, records

personnel may return the documents to the point of origin. The originating clinical work center

must add the missing information for each incomplete entry and then return the document(s)

to the appropriate health record section. (T-3).

5.24. Mental Health Records Documentation Requirements. Mental health records are a

separate category of records that contain detailed psychiatric notations of evaluations,

consultations, tests, and treatment provided on an outpatient or inpatient status. Do not use AF

Form 2100 or 2100A series for records kept in the mental health clinic. These records must be

kept in properly secured files in the mental health clinic. (T-1). See AFI 44-172, Chapter 5, for

details on mental health records and records management.

5.25. Prenatal Records Documentation Requirements. Prenatal records may be maintained

separately by the prenatal clinic and then must be incorporated, as a package, into the inpatient

record at the time of delivery, see Attachment 10 for filing instructions. (T-1). For exceptions, see

the following:

5.25.1. If a patient is transferred or relocates before delivery, give the patient a copy of the

prenatal record to hand-carry to the next MTF. If the patient does not expect to deliver in a

MTF, copies of the prenatal record should be given to the patient and the original documents

scanned into HAIMS.

5.25.2. Prenatal records shall be screened quarterly. (T-1). When the expected date of delivery

has passed or there is no indication that the patient is being followed, the prenatal record should

AFMAN41-210 10 SEPTEMBER 2019 169

be withdrawn from the prenatal file and forwarded to the outpatient records department for

inclusion in the patient’s electronic health record.

5.26. Family Advocacy Program (FAP) Documentation Requirements.

5.26.1. The Family Advocacy clinic or office maintains the original Family Advocacy

Program patient record. The Family Advocacy Program record contains detailed, confidential

information regarding alleged or verified family maltreatment. For every patient visit to the

Family Advocacy clinic, an abbreviated continuity of care entry must be documented in

AHLTA. (T-1). Treatment entries, documenting only minimal information, are inserted into

AHLTA by Family Advocacy Program providers. The continuity of care AHLTA entry most

commonly used indicates: “Patient was seen in Family Advocacy for assessment due to

allegations of family maltreatment.” Other abbreviated or minimally documented statements

or references to one’s suicidal/homicidal assessment and/or a maltreatment risk assessment

will also be included in an AHLTA entry. (T-1). The initial Family Advocacy Program

Clinical Case Staffing (CCS) recommendations will be placed in AHLTA, as well as the

transfer/closure summary for each patient treated in Family Advocacy Program.

5.26.2. When patients are seen in Family Advocacy Program for prevention services, there is

only a requirement for an AHLTA note when there is a clinically significant finding, requiring

documentation for continuity of care or a referral to a medical provider.

5.27. Documentation Requirements to Support Graduate Medical Education

Programs. Documentation requirements will be as outlined by the Accreditation Council for

Graduate Medical Education (https://www.acgme.org) in their common and specific program

requirements. (T-1).

5.28. Managing Service Treatment Records for Service Members Assigned to the Personnel

Reliability Assurance Program and Presidential Support Program

5.28.1. Transferring Service Treatment Records for service members Assigned to a Personnel

Reliability Assurance Program position. Medical records personnel will take all steps

necessary to ensure the gaining MTF has access to the service member’s complete service

treatment record. For service members being assigned to a duty location that does not have

access to the electronic health record [AHLTA/Health Artifact and Image Management

Solution (HAIMS)], a complete copy of their medical record in paper or digital format will be

provided to the service member. (T-0). Reference DoDM 5210.42, Nuclear Weapons

Personnel Reliability Program.

5.28.2. The only exception for hand-carry of outpatient medical records are those service

members in or going into an active Personnel Reliability Assurance Program status whose

record will not be reviewed by the Administrative Qualification Central Cell. Note: These

members must also hand-carry their dental records.

5.28.3. Physical Separation from the Main File for Service Treatment Records of service

members assigned to Personnel Reliability Assurance Program. Outpatient medical and dental

treatment records for Airmen assigned to Personnel Reliability Assurance Program, shall be

maintained in a separate, secured location. (T-1). Access to these physical Service Treatment

Records must be restricted to only those medical personnel with an official need for access.

(T-1).

170 AFMAN41-210 10 SEPTEMBER 2019

5.28.4. Airmen meeting the personnel status conditions identified in Section 5.28.2 are

required to hand-carry their health treatment records (in a sealed envelope) from the losing

MTF or RC to the gaining MTF or to the medical unit responsible for maintaining health

records. Upon arrival to the gaining MTF or to the medical unit, the health records must be

surrendered to the MTF clinic or office responsible for the daily maintenance of these special

records. (T-1).

5.28.5. Before health records are provided to the service member, outpatient and/or dental

records medical and dental record personnel will seal the record(s) in an appropriately sized

envelope, then write or place a pre-worded ink stamp that indicates, “During Transport, Open

Only for Medical Emergencies,” across the envelope sealed flap seam. Then place one strip

of clear or transparent ½ inch adhesive tape down the entire length of the envelope along the

sealed flap seam. Finally, the records management official that seals the envelope must write

official’s initials along the sealed flap seam and legibly write or place a pre-worded ink stamp

that identifies the losing MTF or installation Dental Treatment Facility unit name, office

symbol, address, installation name, zip code, point of contact name and contact telephone

number. (T-3).

5.29. Transferring Health Records Between MTFs or Medical Units.

5.29.1. Transferring Service Treatment Records During PCS, PCA or Permanent Duty

Location Reassignment for Airmen Not Assigned to Sensitive Duties or Active Flight Status.

5.29.1.1. Custody and Control of Outpatient Medical and Dental Records: Hand-carry of

outpatient medical and dental records in a sealed envelope during a PCS or PCA

reassignment is now prohibited for all Airmen, with the exception of Airmen assigned, or

who will likely be assigned, to Personnel Reliability Assurance Program, Presidential

Support Program, and overseas United States embassy support.

5.29.1.2. MTF and RC records managers at the departure or losing MTF or RC are

required to forward the Service Treatment Records for departing service members, to the

gaining MTF or RC responsible for maintaining the service member’s health records. (T-

1). Service Treatment Records will be mailed no later than five duty days following the

service member’s PCS/PCA departure or date of separation/transition to the gaining MTF

or RC. (T-1). Records managers will not mail the records in conjunction with the monthly

purge. (T-3). Records will be mailed on a daily basis as needed. (T-3). Mail the records

via standard First Class United States mail with immediate delivery

confirmation/acknowledgment, certified mail, or other commercially available option, e.g.,

FedEx, that offers package tracking and delivery/arrival confirmation. Use of standard First

Class United States Postal Service mailing method alone

usaf.jbsa.afmoa.mbx.sgat@mail.mil, without package tracking and immediate delivery

confirmation/acknowledgment or certified mail receipt, is prohibited. Return receipt

confirmation must not be dependent upon the timeliness or willingness of the destination

MTF to complete a DD Form 2825 or other manual delivery confirmation receipt option.

(T-3).

5.29.1.2.1. MTF and RC records managers at the departure or losing MTF or RC are

required to expedite the mailing of original outpatient medical and dental treatment

records for departing service members and accompanied family members on PCS

orders to all overseas locations utilizing a commercial carrier (i.e. FedEx or DHL). (T-

AFMAN41-210 10 SEPTEMBER 2019 171

3). The expedited mailing ensures scheduled/guaranteed and tracked delivery of no

more than seven calendar days from the mailing date. United States Postal Service first

class and certified mail do not currently meet this standard – generally taking four to

six weeks for delivery to any OCONUS location. All MTF and RC Outpatient Records

sections have been provided updated and tested mailing addresses for commercial

carriers such as FedEx that only utilize local/physical addresses. The current list of

addresses can be located on the AFMOA Health Benefits Kx page at

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.

5.29.1.2.2. In addition to the requirements of paragraph 5.29.1.2, MTR and RC records

managers will coordinate mail-outs with the Dental clinic to ensure the complete

medical and dental records are mailed together to the gaining MTF/RC. Records will

be mailed with a copy of the member's orders and contain "ATTN: OUTPATIENT

RECORDS" in the address. (T-3).

5.29.1.3. The service member is required to present military PCS orders or duty location

reassignment orders to the departure or losing MTF or to the RC prior to final departure

from the installation or organization. (T-3). Records managers at the losing MTF or RC

will include a copy of the service member’s PCS orders in the same mailing shipment

package bound for the gaining MTF or destination medical unit. (T-3). In the event a copy

of the service member’s PCS orders are not available, the MTF or RC will include a

completed AF Form 330 in place of the orders. (T-3).

5.29.1.4. MTF and Dental Treatment Facility In/Out-Processing PCS Customer Service

Locations: Ideally, each MTF and Dental Treatment Facility should provide one central

in-processing and out-processing customer service location for health records respective to

each facility. For the installation Dental Treatment Facility, this location is usually the

front clinic reception desk. However, some MTFs have decentralized outpatient medical

record rooms. Although one central MTF outpatient medical records customer service

and/or reception area is recommended, MTF commanders or directors may choose instead

to align multiple outpatient medical customer service locations alongside or co-located

with Primary Care Manager or Patient Centered Medical Home clinic operations.

5.29.1.5. Airmen PCS Departure Out-Processing Procedures: All service members

empaneled to the MTF and scheduled for reassignment to another station are required to

out-process through the MTF and Dental Treatment Facility before final installation

departure. The purpose of the out-processing visit is to ensure MTF and Dental Treatment

Facility records managers know to remove the service member’s outpatient medical and

dental records from the main file and prepare the record(s) for shipment to the gaining

MTF.

5.29.1.6. Airmen projected for installation departure related to a PCS reassignment are

required to clear the Dental Treatment Facility and MTF no earlier than the fifth duty day

before their final installation out-processing Military Personnel Section appointment. (T-

3). This time period restriction ensures outpatient medical and dental records will be

readily available to medical and dental providers up until the time the member leaves the

base.

5.29.1.7. During each respective out-processing appointment, Airmen are required to

provide four copies of their orders (two copies for the Dental Treatment Facility, two copies

172 AFMAN41-210 10 SEPTEMBER 2019

for the MTF). (T-3). Depending on local operating policy, service members may be

required to visit a centrally located MTF records customer service office or out-process

through their Primary Care Manager records room location. MTF & Dental Treatment

Facility records personnel will ensure local installation out-processing checklists include

MTF & Dental Treatment Facility records out-processing requirements. (T-3).

5.29.1.8. Dental Treatment Facility Record Processing: No later than the close of business

each duty day, Dental Treatment Facility records managers will ensure two copies of each

departing Airman’s PCS reassignment orders are filed properly. (T-3). One copy will be

placed on top of all other documents in Section II of the AF Form 2100B series. The

second copy will be placed in a plastic AF Form 885-887 series.

5.29.1.8.1. Complete an AF Form 250 and insert into the upper right identification slot

on the charge-out-guide. File the charge-out guide into the main file according to

terminal-digit order - just like the original dental record. The charge-out guide will

remain for 90 calendar days. At the end of this period, if any loose, late-flowing dental

documents are discovered, place the documents and the copy of the PCS reassignment

order in an envelope and mail directly from the Dental Treatment Facility to the

member’s gaining Dental Treatment Facility. Do not forward these late, loose flowing

documents to the MTF outpatient records office.

5.29.1.8.2. No later than the close of business on the duty day following the member’s

out-processing visit, Dental Treatment Facility records managers will forward the

dental treatment record(s) to either a central MTF records room or to the Primary Care

Manager records room where the service member is empaneled. (T-3). After receiving

the dental treatment record(s), MTF records managers may temporarily stage the

records in a separate location, away from the main outpatient medical file. Local MTF

policy must be established to identify the best method for transferring the dental

treatment records from the dental clinic to the MTF. (T-3).

5.29.1.8.3. Dental record managers will document the date and forwarding location of

each dental treatment record removed from the dental records main file using the

current local or standard dental records tracking mechanism. (T-3)

5.29.1.9. MTF Record Processing: No later than the close of business each duty day, MTF

records managers will ensure two copies of each departing Airman’s PCS reassignment

orders are filed properly. (T-3). One copy will be placed on top of all other documents in

Section II of the AF Form 2100A series. The second copy will be placed in a plastic AF

Form 885-887 series.

5.29.1.9.1. Complete an AF Form 250 and insert into the upper right identification slot

on the charge-out-guide. File the charge-out guide into the main file according to

terminal-digit order - just like the original outpatient medical record. The charge-out

guide will remain for 90 calendar days. (T-3).

5.29.1.9.2. MTF records managers must mail the medical and dental records bundled

together and follow the procedures outlined in paragraph 5.29.1.2. (T-3).

5.29.1.9.3. Select and enter the appropriate transfer code in the CHCS Medical Record

Tracking module and enter the name of gaining MTF in the “MTF Location Remarks

Section.”

AFMAN41-210 10 SEPTEMBER 2019 173

5.29.1.9.4. After 90 days, retrieve the charge-out guide from the main file and scan

any loose or late flowing documents that may have collected in the charge-out guide

into the HAIMS repository or into another approved electronic health record.

5.29.2. Transferring Service Member Service Treatment Records During PCS, PCA or Duty

Location Reassignment to Forward or Foreign Combat/Combat Support Theater of Operations

Locations, or Other Overseas Deployment Locations for Airmen Not Assigned to Sensitive

Duties or Active Flight Status.

5.29.2.1. For 365-day PCS and/or extended deployments the service member’s original

service treatment record will remain at the MTF where the service member is enrolled. (T-

3). Upon return records staff will forward the original service treatment record to the

gaining assignment once written direction or orders are received. (T-3). Obtain two copies

of the PCS orders and place one copy of each inside the original outpatient medical and

dental treatment records in Section I or attach to the left side folder flap on top of most

current DD Form 2766, dental treatment encounter form, service transition order, or AF

Form 1288.

5.29.2.2. Unless exempted by the COCOM/Component Reporting Instructions, following

the AD or RC service member’s deployment medical clearance, established during the

MTF pre-deployment screening, and before the service member finishes departure PCS

out-processing, print the most current version of the ASIMS DD 2766 and place them into

the cardstock DD Form 2766 (secured with the metal prongs). Include paper copies of any

medical information that documents chronic medical conditions or any documents ordered

to be copied and placed into the service member’s DD Form 2766. The service member

(or deployment team leader) is responsible for transporting the original DD Form 2766

along with the documents listed above, leaving the original Service Treatment Record and

a copy of the DD Form 2766 behind at the service member’s home MTF.

5.29.2.3. When the service member returns to home installation, the DD Form 2766 and

any documents generated in theater are removed from the DD Form 2766 and scanned into

patient’s electronic health record. If the service member has received an order to proceed

to a follow-on PCS re-assignment installation, the gaining MTF will request the service

member’s original Service Treatment Record from the departure or losing home

installation MTF. (T-3).

5.29.2.4. Exception: When a service member receives a 365-day PCS order to a deployed

location where the site is adequately resourced to manage medical records, exercise 24/7

operations and have an approved waiver authorizing the maintenance of medical records,

the member may hand-carry a copy of their service treatment record. The losing MTF will

forward the original service treatment record to the gaining deployed location (in a sealed

package secured by the departure MTF). (T-2). Upon arrival, the service member is

required to relinquish their Service Treatment Record to the Expeditionary Medical

Support facility or to the installation MTF. (T-3). These facilities will be identified and

added to the exception list maintained by the AFMOA/SGAT.

5.29.3. Transferring service member Service Treatment Records During PCS, PCA or Duty

Location Reassignment for Air Force Members Empaneled to Sister-Service MTFs. The fact

that some Airmen are enrolled to non-Air Force MTFs does not prohibit the accurate and timely

health records transfer process. Health records for service members are normally maintained

174 AFMAN41-210 10 SEPTEMBER 2019

at the MTF where the member obtains primary care, regardless of service affiliation. To

facilitate appropriate health records transfer procedures for Air Force service members the

following actions must occur. (T-3). Health records staff at Air Force MTFs nearest to the

service member’s sister-service Primary Care Manager/MTF location must establish a local

memorandum of agreement or memorandum support agreement. (T-3). The agreement with

the sister-service MTF and the service member’s servicing Military Personnel Section will

ensure all final out-processing documents, checklist requirements, Military Personnel Section-

generated PCS notices, and PCS orders are completed and/or forwarded. (T-3). The agreement

must identify how the health records of Air Force personnel will transfer to the MTF at the

next duty location. (T-3). Transfer options may include, but are not limited to instructions that

specify health records, a) be mailed to the requesting Air Force MTF by the sister-service MTF

or, b) forwarded to the MTF at the Airman’s next duty location.

5.29.3.1. Note: Local procedures may be required if an agreement on how to forward

medical records cannot be reached between the sister-service primary care manager or

MTF, the local installation military personnel section and the MTF nearest the service

member’s GSU. If such an impasse occurs, the local military personnel section and the

nearest MTF to the GSU may have to initiate local procedures to ensure the Airman’s

health records are properly forwarded and delivered to the Airman’s next duty station.

5.29.4. AD Virtual Military Personnel Section Checklist Confirmation. Although the Force

Health Management staff may have additional medical out-processing checklist approval

authority or obligations, they should not sign or approve any outpatient medical or dental

treatment record out-processing tasks on a service member’s Virtual Military Personnel

Section out-processing checklist. Outpatient medical and dental records managers and Force

Health Management officials will work together to ensure each outbound Airmen has fulfilled

all the MTF out-processing responsibilities.

5.29.4.1. Checklist Operation: Multiple (at least two) staff members assigned to MTF and

Dental Treatment Facility records departments should be granted Virtual Military

Personnel Section Checklist access to ensure each departing service member is informed

of the requirement to provide the MTF and Dental Treatment Facility with copies of orders

at the time of MTF/Dental Treatment Facility out-processing.

5.29.4.2. Access will also allow MTF records managers to obtain and print individual

retirement/separation orders when necessary.

5.29.5. Transferring Outpatient Medical and Dental Records between MTFs for Family

Members, Retired Military Service Members, or Any Other Category of Beneficiary Not

Specifically Captured in this Section.

5.29.5.1. MHS beneficiaries are prohibited from hand-carrying their medical records. The

standard procedure throughout the AFMS is to mail family member hard-copy outpatient

medical records from one MTF to another during reassignments. Only the MTF

commander or director can make a case-by-case exception to deviate from this process.

5.29.5.2. Upon notification from the sponsor of being re-assigned to another installation

several actions must take place. MTF records personnel will check the typed PCS/PCA

orders to determine if the reassignment is to be “ACCOMPANIED” (with family members)

or “UNACCOMPANIED” (without family members). (T-3). If the service member’s

AFMAN41-210 10 SEPTEMBER 2019 175

orders indicate an ACCOMPANIED assignment, records personnel will ask the service

member if all of the family members are to accompany. (T-3). If all family members are

accompanying the service member, then records personnel will verify the departure date

with the sponsor. (T-3). Records personnel will obtain any available dental treatment

records, and then combine all of the family member health records into one package. (T-

3). MTF records personnel may also add the sponsor’s Service Treatment Record into the

same package. If the package is too big or it becomes impractical to combine all of the

family’s records together, then separate the service member’s record from the package and

mail separately. Enclose a copy of the sponsor’s typed PCS/PCA reassignment orders in

each package. Mail the health records package(s) to the destination MTF no later than five

calendar days following the sponsor’s departure date.

5.29.5.3. If the sponsor’s orders indicate UNACCOMPANIED or the sponsor indicates

one or more family members are not accompanying, records personnel must validate family

member enrollment. Records personnel must verify with the sponsor if the remaining

family members will stay enrolled at the current MTF. (T-3). If not the remaining health

records should be forwarded to another facility where TRICARE enrollment is expected.

(T-3). The following actions must take place when family members are expected to receive

direct healthcare at another MTF, apart from where the sponsor. (T-3). Upon re-enrollment

at the new MTF, the sponsor, spouse, or legally-aged (per state law) family member must

contact the records department to complete the necessary records request paperwork. (T-

3). After receiving a completed DD Form 2138, or DD Form 877 from the requesting

MTF, the current MTF will release and forward the requested records. (T-3).

5.29.5.4. For Retired Service Members, and/or Their Family Members, and AD Family

Members Who Wish to Change Their MTF TRICARE Enrollment Location Without

Associated Sponsor PCS/PCA. This process is required whether the move be across the

country or within a multi-market service location (e.g., changing MTF/Primary Care

Manager location within the San Antonio, TX; Washington, DC; or Hampton

Roads/Norfolk/Portsmouth, VA - Tidewater area). Inform the sponsor that upon arrival

and/or TRICARE re-enrollment at the new MTF, the sponsor, spouse, or legally-aged

family member must contact the outpatient medical records department to complete the

necessary records request paperwork. (T-3). Only after receiving a properly completed

DD Form 2138 or a DD Form 877 or another suitable request form (from the requesting

MTF) will the MTF (where health records are currently maintained) release and forward

the requested records. If the sponsor contacts the departure or losing MTF before the

anticipated MTF change, provide the sponsor with a DD Form 2138. Instruct the sponsor

to complete Sections I and II of the form and deliver the form to the MTF records

department at the gaining MTF where TRICARE re-enrollment is expected.

5.29.5.5. Under all circumstances, CONUS based MTFs/RCs mailing health records or

loose, late flowing medical documents to other stateside CONUS MTFs/RCs will follow

the mailing procedures outlined in paragraph 5.29.1.2. (T-3).

5.29.5.5.1. Under all circumstances, OCONUS based MTFs/RCs mailing health

records or loose, late flowing medical documents to other OCONUS and CONUS

MTFs/RCs will use a commercial carrier (i.e. FedEx or DHL). (T-3).

176 AFMAN41-210 10 SEPTEMBER 2019

5.29.5.5.2. Use of United States Postal Service first class and certified mail are not

authorized.

5.29.5.6. MTF commanders or directors (Custodians of Record or their delegates) may

make exceptions to the hand-carrying policy on a case-by-case basis if extenuating

circumstances warrant it. No sponsor is authorized to possess or hand-carry the original

health records or copies of health records for any member of the family aged 18 years or

older without written authorization from the family member.

5.29.5.7. Forward health records critical to potential, pending, or active litigation using

only shipping options with an immediate delivery confirmation/acknowledgment feature.

(T-3). Shipping options may include certified mail via official military mail, United States

Postal System or other commercially available option, e.g., FedEx, that offers package

tracking and arrival confirmation. Use of standard First Class United States Postal Service

mailing method alone, without immediate delivery confirmation/acknowledgment, is

prohibited. (T-3).

5.29.6. Disposition of Family Member Outpatient Medical and Dental Records When the

Sponsor has a 365-day PCS to an Overseas Location in Support of Contingency Operations.

5.29.6.1. If the service member’s PCS is identified as ACCOMPANIED on the sponsor’s

orders, the outpatient medical and dental records for all family members will remain at the

losing or “home base” facility until the service member either returns from deployment or

receives a follow-on PCS assignment to another location. (T-3). Only upon request,

provide copies of family member medical records (including AHLTA patient encounters)

to the sponsor and/or any legally-aged family member.

5.29.6.2. Upon return from a 365-day PCS overseas location, if the sponsor receives a

follow-on assignment to a different installation the member will contact the gaining MTF

upon arrival (at the new installation) and initiate a formal request to obtain family-member

dependent medical records from the losing MTF. (T-3).

5.29.6.3. If the service member’s PCS is identified as UNACCOMPANIED on the orders,

determine where the family member’s MTF TRICARE enrollment is expected and follow

protocol outlined in Section 5.29.5.3.

5.29.6.4. Insert a charge out guide with a copy of PCS orders, DD Form 877, or DD Form

2138. Scan all loose medical documents in the approved electronic health record.

5.29.7. Transferring Mental Health Records. See AFI 44-172 for procedures detailing the

transfer of Mental Health Records.

5.30. Providing Health Records to AD Members During Temporary Duty Periods.

5.30.1. With the enterprise-wide use of the electronic health record, there are very few

situations where an Airman would be required to bring paper outpatient and/or dental records

to a TDY location. Most Professional Military Education (PME) and technical training schools

no longer require students to bring a copy of their medical record or copies of recent

encounters. As a general rule, MTF outpatient records departments should only provide a

complete copy of outpatient medical record to the member if, a) specifically required per

formal training requirements (TDY orders must include this requirement in writing on the

orders), b) if the member has a chronic medical condition where reference of the medical record

AFMAN41-210 10 SEPTEMBER 2019 177

could be useful during treatment at the TDY location, or c) in any situation that a provider

deems medically necessary for the member to hand-carry the record while TDY. Ensure all

pertinent electronic health record documents are printed and filed into the record prior to the

service member’s departure. If a copy of the health record is to be provided, the record(s) must

be enclosed in a strong envelope or package and sealed. (T-3).

5.30.2. MTF Staff who care for Personnel Reliability Assurance Program members while

member is in TDY status will help to ensure that appropriate documentation and notifications

are made to member’s home unit. (T-3). Following the completion of all official TDY

assignments, the TDY assignment location MTF staff will ensure that the member receives a

copy of all medical documentation that occurred during the member’s TDY assignment. (T-

3).

5.30.3. All TDY Airmen normally assigned to a Personnel Reliability Assurance Program

position who are not expected to perform or fill an active operational Personnel Reliability

Assurance Program position or job at the TDY location, are not required to hand-carry their

Service Treatment Record to the TDY. Following each episode of care at the TDY location,

personnel assigned to the Personnel Reliability Assurance Program, flight medicine clinic or

any official(s) responsible for managing the integrity of the MTF portion of the Personnel

Reliability Assurance Program notification system, will print out a copy of the electronic health

record note and mail a copy (via Certified military or United States Mail with immediate

delivery confirmation/package tracking) to the MTF at the Airman’s home station. (T-3). MTF

personnel at the TDY location will also provide a copy of the printed electronic health record

note to the service member. (T-3). The service member is required to bring the printed

electronic health record note to the provider at home station. The returning Airman’s provider

is required to review the electronic health record document (either the mailed copy or the copy

provided by the service member) to identify any potential medical issues that could jeopardize

overall program integrity or reliability based upon the patient’s capabilities/limitations (if any)

documented or identified at the TDY location. (T-3)

5.30.4. Before copies of health records are provided to the member, outpatient and/or dental

records personnel will follow the procedures for sealing the records that are set out in paragraph

5.28.5. (T-3).

Section 5C—Inpatient Records Administration

5.31. Creating Inpatient Records.

5.31.1. MTFs that create and maintain inpatient records will use guidelines from this chapter

and from Joint Commission standards. (T-0). Records must to be completed within 30 days

after the patient’s discharge in accordance with Joint Commission standards. (T-0) Reference

The Joint Commission Standards at

https://www.jointcommission.org/facts_about_joint_commission_accreditation_standar

ds/.

5.31.2. MTFs will create an inpatient record for the following episodes (T-0):

5.31.2.1. Patients admitted to an inpatient unit of an Air Force MTF including patients

admitted and discharged before midnight on the day of admission regardless of the type of

discharge.

178 AFMAN41-210 10 SEPTEMBER 2019

5.31.2.1.1. Reactivate the record of hospitalization if the patient is readmitted before

midnight on the same day as discharged for the same reason as the first admission. The

attending provider annotates the reason for readmission and the hospitalization is

considered as one continuous period.

5.31.2.1.2. If the patient is readmitted after midnight, or the reason for readmission is

different from that of the previous admission, create a new record.

5.31.2.2. Live births occurring in an Air Force MTF. Note: Do not create a separate

record for stillbirth infants. All paperwork, including the autopsy (if performed), will be

filed in the mother’s inpatient record. (T-3).

5.31.2.3. Patients who die in transit. The MTF receiving the remains processes the records

and completes the AF Form 565 as if the patient had transferred in.

5.31.2.4. All patients admitted to an Expeditionary Medical Support facility or fixed

contingency hospital during deployment. See Section 5D, Deployed Assignment Medical

Record Management for further instructions.

5.31.3. A canceled admission may be appropriate in some instances. Annotate the admission

worksheet with the reason for cancellation and place all paperwork generated by the admission

(e.g., history and physical, progress notes, laboratory and x-ray reports, etc.) in the patient’s

electronic health record. Record and code the episode as an outpatient encounter.

5.32. Creation of the Master Patient Index.

5.32.1. The Master Patient Index serves as an alphabetical index of all hospital patients and

patients for whom administrative responsibility is assumed (e.g., AD military in non-federal

hospital). Note: Do not destroy - maintain for 50 years.

5.32.2. The Master Patient Index is created by and stored in the current automated system.

5.32.3. MTFs without automated Admissions & Dispositions Office functions will maintain

hard-copy paper index cards.

5.33. Preparing Inpatient Record Folders.

5.33.1. Create records at time of disposition and completion of each patient hospitalization for

future retirement. Ensure discharge summary is scanned/uploaded into approved electronic

health record. Number folders according to the sponsor’s social security number. Place an

automated bar code patient identification label in the upper right corner of the record jacket

cover in the Patient Identification block. Document the record jacket cover according to the

following table:

Table 5.3. Preparing Inpatient Record Folders.

If the patient is:

Use social security number of:

AD/RC

Service Member

Family Member

Sponsor

Civilian Employee

Employee

Retired military

Member

Civilian Emergency

Patient

AFMAN41-210 10 SEPTEMBER 2019 179

Foreign national, allied or other military member

without social security number

Construct a social security number

5.33.2. See paragraph 5.10.6 for guidance regarding the creation of a pseudo social security

number when a patient’s own social security number is not known or does not exist.

5.33.3. MTFs that create and maintain inpatient records will use AF Form(s) 788A-788J

series, as appropriate, according to the last two digits of the applicable social security number.

To increase the likelihood that the paper inpatient record will be filed and retrieved easily,

enter information on the front of the folder as indicated by the following paragraphs. See

paragraph 5.36 for filing instructions.

5.33.3.1. Print the first name, middle initial, and last name of the patient in the space

provided with a black pen, felt-tip marker, or embossed card. Address labels prepared by

the Personnel Data System may be used to provide names of military personnel. DO NOT

use pencil for any entry. Always place information in the upper right-hand corner of the

jacket cover in the patient Identification area.

5.33.3.2. Enter the sponsor’s social security number in the preprinted blocks in the upper

right-hand corner of the record.

5.33.3.3. Enter the family member prefix in the two circles next to the social security

number.

5.33.3.4. Fill in the ½-inch square block, along the right edge of the back leaf of the folder,

containing the same digit as the last digit of the social security number, with a black ink

pen, felt-tip marker, or black tape.

5.33.3.5. On the outside, front cover of the inpatient record jacket, in the pre-printed or

labeled treatment year grid section, fill-in the current treatment year that corresponds to the

patient’s most recent inpatient treatment. Use a black felt-tip marker or black pen.

5.33.3.6. Indicate the patient’s status in the appropriate block on the front.

5.33.3.7. Attach the CHCS Medical Record Tracking bar code label to the inpatient record

folder. See the Medical Record Tracking, Retirement and Retrieval User Guide for

instructions on label requirements.

5.33.3.8. Stamping or labeling the front cover of the inpatient record with any large-letter

identifiers other than “CROSS-REFERENCE,” or with infant-adoption related

notifications is discouraged. See paragraph 4.3.3.1 for detailed information regarding

infant-adoption medical information release instructions.

5.33.4. Documents placed in the folder may be held together with a 3-inch fastener or fastened

into the folder. When records are retired to the National Personnel Records Center, documents

are permanently affixed to the folder.

5.34. Contents of the Inpatient Record.

5.34.1. Upon the patient’s disposition, MTFs will arrange paper copies of forms in the order

listed below as applicable to the case. (T-1). Note: As MTFs increase their use of Essentris

or other automated systems to create a computer-based patient record, the style and

arrangement of data in the electronic record may vary from the guidance provided here.

Records printed from automated systems should be assembled as closely as possible to the

180 AFMAN41-210 10 SEPTEMBER 2019

traditional inpatient record until more detailed instructions are published. An asterisk “*”

denotes that the form may not be filed in the order listed. See special instruction column in

Attachment 10 for proper filing location. Command and locally developed medical forms

should be filed in the appropriate order as according to purpose. See Attachment 10 for

arrangement of forms in the inpatient record.

5.34.2. Problem Oriented Medical Record. If a MTF elects to use the Problem Oriented

Medical Record format, then the MTF will develop local directives to prescribe which cases

will use this format, the method by which the forms are used and the manner in which the

forms will be filed. (T-3).

5.34.3. Self-Determination Act (Advance Directive) Documents. When provided by the

patient (at each admission), the documents (which may include the living will, durable power

of attorney, and/organ donation paperwork) will be filed with the other administrative

documents in the record. (T-3). After discharge, the patient may take the original documents

home with them and bring them back if admitted again at some future date. At the time of

discharge, the MTF inpatient nursing ward clerk will make a copy of the Advance Directive

document(s) and replace into the electronic health record for reference. (T-3).

5.35. Inpatient Record Documents, Forms, and Patient Identification.

5.35.1. Inpatient records consist of the original copy of the forms listed in Attachment 10 as

applicable to the case. Each form filed in the inpatient record must contain, at a minimum:

Patient name (last, first, middle name or initial), Register Number, patient’s DoD Identification

Number, patient’s family member prefix, patient’s and sponsor’s social security number, and

MTF organization and/or treatment name. (T-1).

5.35.2. SFs Available on Internet. Many SFs are now available at the GSA Forms Library

website. Most forms are in “PDF” format and should be downloaded with the Adobe Reader,

available on the website. Forms not available on the website must be ordered from: (T-1).

GSA-FSS

General Products Commodities Center

ATTN: 7FSM

819 Taylor Street

Fort Worth, TX 76102

5.35.3. See Section 5A for guidance on overprinted and electronically generated forms.

5.35.4. Dictated and Transcribed Medical Forms. Providers, at the time of dictation, will

indicate the date and time of the dictation, their clinical occupational specialty, and their Air

Force Specialty Code (AFSC), if applicable. Transcriptionists will include the aforementioned

data, the transcribed clinical content, and the date of transcription on all transcribed reports,

such as SFs 502, 504-506, 516, Operation Report, etc. (T-1).

5.36. Filing Inpatient Records.

5.36.1. Preparation of folders, arrangement of content, and record filing methodology is

consistent throughout Air Force MTFs.

5.36.2. File records in terminal digit format by social security number.

AFMAN41-210 10 SEPTEMBER 2019 181

5.36.3. For discharges in Calendar Year 2003 and earlier, records of previous admissions may

be brought forward and filed, as a separate entity, in the folder of the current admission record.

5.36.4. Beginning with discharges as of 1 January 2004, file each admission in a separate

folder. There is no requirement to re-file admissions in a separate folder for discharges

occurring prior to 1 January 2004.

5.36.5. Only authorized personnel at the MTF may access inpatient records. Substitute an AF

Form 614 for the inpatient record when removed from the file and charge out the record in the

Medical Record Tracking module of CHCS.

5.36.6. Fetal Monitor Strip Filing Procedures. Maintain the fetal monitor strips on the

obstetrical unit with the prenatal record until delivery.

5.36.6.1. After discharge of the infant, send the fetal monitor strips to the inpatient records

department for maintenance until retirement to the National Personnel Records Center.

Annotate the envelope with the name and register number of the infant, sponsor’s name

and social security number, name of the MTF, and date of infant’s birth.

5.36.6.2. Place strips in envelopes that will be filed in record folders when retired to

National Personnel Records Center. Note: Digitized, or other format, fetal monitor strips

which can be printed out on an 8 1/2” X 11” document are filed in the infant’s inpatient

record or the mother’s if the infant is stillborn. Attach the CHCS Medical Record Tracking

bar code label to the folder.

5.36.6.3. When an undelivered patient is transferred, send all fetal monitor strips prepared

with the copy of inpatient records to the receiving MTF.

5.36.6.4. Send the fetal monitor strips with the patient, when a newborn is transferred to

another MTF during initial hospitalization.

5.36.6.5. File fetal monitor strips for stillborn infants, as defined by the Center for Disease

Control and Prevention (CDC) and/or State guidelines as appropriate, under the register

number of the mother.

5.36.6.6. In instances where the case outcome is unclear, send the outpatient fetal monitor

strips to the inpatient record department. File the fetal monitor strips in a record created

under the mother’s name, family member prefix and sponsor’s social security number.

5.36.6.7. All fetal monitor strips will be retired to National Personnel Records Center in

the same shipment as the inpatient records and the extended ambulatory record. (T-3).

5.37. Coding and Documenting Inpatient Records.

5.37.1. Coding of Inpatient Records.

5.37.1.1. All diagnoses and procedures are to be written in full, without symbols or

abbreviations, in acceptable provider terminology.

5.37.1.2. Sequence and code the diagnoses and procedures according to the current version

of the International Classification of Diseases (ICD) or other government approved coding

classification system.

5.37.1.3. Signatures are required on all documentation before the record is coded. (T-2)

182 AFMAN41-210 10 SEPTEMBER 2019

5.37.1.4. After coding the record, prepare and print the final cover sheet (AF Form 565 or

automated equivalent).

5.37.1.5. At the end of each month, create the Standard Inpatient Data Record and transmit

it by the 5th working day.

5.37.2. The provider’s social security number must not appear anywhere in the patient’s

inpatient record. (T-1).

5.37.3. AF Form 560 - Use this form as a worksheet for admitting the patient and for recording

final diagnoses and procedures.

5.37.3.1. Demographic information can be entered directly into the current automated

system, without duplicate entry of the same information on AF Form 560. It is not

necessary that the AF Form 560 be an exact copy of the final automated coversheet.

5.37.3.2. The appropriate healthcare provider completes AF Form 560 at discharge and

authenticates the entry and identifies himself or herself by signature, initials and use of a

signature block/name stamp.

5.37.3.3. Upon receipt of the inpatient record, inpatient records personnel review the entire

record to ensure completeness and accuracy of diagnostic and procedure information on

the AF Form 560. If a question arises, consult the provider for clarification. The provider

completing the form makes the final decision regarding additions and deletions of

diagnoses and procedures.

5.37.3.4. Sequence and code the diagnoses and procedures using the current version of the

International Classification of Diseases. Prepare the final cover sheet (AF Form 565 or

automated equivalent) after all information has been checked and completed.

5.37.3.5. Disposition of the AF Form 560.

5.37.3.5.1. The original worksheet is filed in the inpatient record.

5.37.3.5.2. A copy of the AF Form 560 is scanned and uploaded when used in lieu of

an AF Form 565.

5.37.4. AF Form 565. Use this form or automated equivalent as the final cover sheet of each

record to provide an administrative and clinical summary of each admission.

5.37.4.1. The cover sheet is used to summarize the inpatient episode of care with the

identification of the principal diagnosis and procedure, any co-morbidities (presence of one

or more conditions simultaneously with a primary condition), or complications, and the

sequencing of the diagnoses and procedures. Provider terminology will be used for

diagnoses and procedures. (T-3). No provider signature is required on the cover.

5.37.4.2. At local MTF option, a stamp indicating that the record was created for

administrative purposes only may also be used.

5.37.4.3. Use AF Form 565 in death cases for persons who are inpatients at the time of

death.

5.37.4.4. Disposition of AF Forms 565.

5.37.4.4.1. Insert the original AF Form 565 in the inpatient record.

AFMAN41-210 10 SEPTEMBER 2019 183

5.37.4.4.2. Scan and upload a copy of the AF Form 565 in the outpatient record after

final disposition of the case.

5.37.4.4.3. Scan and upload a copy of the AF Form 565 in the outpatient record of

patients being transferred to another facility.

5.37.5. The Joint Commission (https://www.jointcommission.org) mandates that “a concise

discharge summary providing information to other caregivers facilitating continuity of care

includes the following: the reason for hospitalization; significant findings; procedures

performed and care, treatment, and services provided; patient’s condition at discharge; and

instructions to the patient and family as appropriate.” Consideration should be given to

instructions relating to physical activity, medication, diet and follow-up activity. The condition

of the patient on discharge should be stated in terms that permit a specific measurable

comparison with the condition on admission, avoiding the use of vague relative terminology,

such as “improved.” When preprinted instructions are given to the patient or family, the record

should so indicate and a sample of the instruction sheet in use at the time should be on file in

the medical record department.

5.37.5.1. The healthcare provider dictates a concise clinical resume (narrative summary)

which is transcribed on the SF 502 for:

5.37.5.1.1. Patients hospitalized eight days or longer.

5.37.5.1.2. Patients received by transfer from another MTF for further medical

treatment regardless of the length of stay.

5.37.5.1.3. Patients who die after admission.

5.37.5.2. The narrative summary may be handwritten on the SF 502 if the patient has been

hospitalized less than eight days.

5.37.5.3. When a patient is transferred to another medical facility for further care, a

handwritten summary will be completed. If, for expediency’s sake, a quick transfer note

is written, a written or dictated summary will follow. (T-3).

5.37.5.4. Final progress notes on SF 509 may be substituted for narrative summaries on

patients with minor problems requiring less than a 48-hour stay, normal newborn infants

or uncomplicated obstetrical deliveries. Include any instructions given to the patient or

family in the final progress note. Scan and upload a copy in the patient’s outpatient record.

5.37.5.5. Disposition of SF 502:

5.37.5.5.1. File the original in the patient’s inpatient record.

5.37.5.5.2. Scan and upload a copy in the patient’s outpatient record.

5.37.5.5.3. Send one copy to the Commandant (G-KMA), United States Coast Guard,

Washington DC 20590, when United States Coast Guard members on AD are

discharged.

5.37.5.5.4. Upon disposition of a uniformed services member who is already on the

Temporary Disability Retired List when admitted, send a copy of the AF Form 565 and

SF 502 to the parent service as indicated below:

Air Force:

184 AFMAN41-210 10 SEPTEMBER 2019

HQ AFPC/DPSD

550 C Street West

Randolph AFB TX 78150

Navy:

Department of the Navy

Bureau of Medicine and Surgery (MED-25)

2300 E St., NW

Washington DC 20372-5300

Public Health Service and National Oceanic Atmospheric Administration

Medical Affairs Branch

ATTN: Dr. David Hooper

Department of Health and Human Services

5600 Fishers Lane, Rm 4C-06

Rockville, MD 20857

5.37.6. For an AD patient pending final disposition of PCS to home or transfer to a VA

hospital, place all additional copies of the AF Form 565 (or AF Form 560 when used in lieu

of) and SF 502 in a suspense file. Keep the patient in a change-of-status category until final

disposition of the case. Upon disposition, patient administration personnel complete the

administrative data on the final cover sheet (i.e., regarding type of disposition, etc...) and file

the following forms as specified in Attachment 10.

5.37.7. SF 504, SF 505, and SF 506.

5.37.7.1. Healthcare providers complete the history and physical examination records

within 24 hours after admission.

5.37.7.1.1. Completion of any part of the history or physical examination by a medical

student/physician’s assistant student does not relieve the attending healthcare provider

of the responsibility to ensure that an adequate history and physical examination is

performed and documented. See AFI 44-119, Medical Quality Operations for

procedures concerning histories and physicals conducted by medical/physician’s

assistant students.

5.37.7.1.2. The certified nurse mid-wife completes the history and physical

examination on obstetrical patients for whom the mid-wife is responsible.

5.37.7.1.3. A properly credentialed oral surgeon completes the physical examination

for patients admitted for dental services.

5.37.7.1.4. Podiatrists complete the history and physical as applicable to the podiatry

problem.

5.37.7.2. If an adequate history and physical examination is sent with transfer-in patients,

the provider may document an interval note on SF 509 stating no changes. The provider

will document any important changes.

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5.37.7.3. Enter a note in the SF 509 referring to the previous history and physical

examination for patients readmitted within one month to the same MTF for the same

condition. Document any changes. If desired, place a copy of the previous history and

physical in the current record.

5.37.7.4. If a history and physical examination was performed within 30 days before

admission, such as in the physician’s office, place a durable, legible copy in the inpatient

record and document any changes in the SF 509.

5.37.8. DD Form 2770, Abbreviated Medical Record may be used for the following:

5.37.8.1. Hospitalizations of five days or less for minor medical conditions normally

treated on an ambulatory basis when care in the patient’s residence is inadequate.

5.37.8.2. Hospitalizations of two days or less for minor surgical procedures performed

under local or peripheral nerve block anesthesia. This includes stable anesthesia Class III

or IV with minor procedure under local or regional anesthesia with or without IV sedation.

5.37.8.3. Hospitalizations of five days or less for delivering obstetric patients whose intra-

partum and postpartum course is uncomplicated, provided that a complete prenatal record

is included in the inpatient record.

5.37.8.4. Hospitalizations of 48 hours or less for surgeries when the patient is clearly

anesthesia Class I or II, regardless of type of anesthesia used.

5.37.9. Prepare SF 535 in duplicate for all newborn infants. Include the original in the

newborn’s inpatient record. Scan and upload information into the patient’s electronic health

record.

5.37.10. Record the patient’s diagnosis, treatment and care on the SF 509 to chronologically

describe the clinical course of the patient.

5.37.10.1. Determine the frequency of the notes based on the patient’s condition. Make

daily notations for the following: the first five days after a patient has undergone a major

operation; if the patient is seriously ill.

5.37.10.2. Record the postoperative note on the SF 509. The form may be overprinted

locally to provide a format.

5.37.10.3. Document the informed consent on the SF 509. See AFI 44-102 for

instructions.

5.37.11. Report surgical operations, including those performed in the ambulatory surgery unit,

on SF 516.

5.37.11.1. According to Joint Commission requirements, providers/surgeons will dictate

the report immediately following surgery. (T-0).

5.37.11.1.1. If immediate dictation is not feasible, dictate the report no later than 24

hours following the end of the surgical procedure.

5.37.11.1.2. If the operative report is not placed in the medical record immediately

after surgery, then prior to the patient’s release from the Recovery Room, the provider

will draft and enter an operative note into the inpatient or ambulatory procedure record

indicating pertinent clinical information to ensure continuity of care.

186 AFMAN41-210 10 SEPTEMBER 2019

5.37.11.2. Providers, at the time of dictation, must include the date and time of the

dictation, their clinical occupational specialty, and their AFSC, if applicable. (T-2).

Transcriptionists will include the aforementioned data, the transcribed clinical content, and

the date of transcription on all transcribed reports, including operative reports, SFs: 502,

504-506, 516, etc. (T-3).

5.37.11.3. Include in the report a description of the findings, the technique used, the tissue

removed or altered, estimated blood loss, as indicated, the postoperative diagnosis, the

condition of the patient at the end of the operation, and the name of the primary surgeon

and assistants.

5.37.12. Laboratory and Radiology Reports. When a computerized or automated summary of

all laboratory and radiology report results compiled during the patient’s hospitalization is

provided, file only the cumulative final report with the exception of preadmission labs and x-

rays. Destroy all previous duplicated computerized/automated report results. For inpatient

records unlike outpatient, all laboratory and radiology results must be filed in the record upon

discharge from the hospital. (T-3).

5.37.13. AF Form 3066 or 3066-1. A provider signs and dates orders on the AF Form 3066

or 3066-1, or enters the information into the current automated system.

5.37.13.1. When a hardcopy AF Form 3066 or 3066-1 is utilized, maintain the original

with the patient’s inpatient record.

5.37.13.2. When medications are ordered, send a copy to the Pharmacy. The provider’s

Drug Enforcement Agency (DEA) number is required in the provider’s signature

block/name stamp for any hand written prescriptions for controlled substances. Non-

United States physicians and dentists assigned to overseas facilities use their medical or

dental license number instead of a Drug Enforcement Agency number. (See AFI 44-102).

5.37.13.3. A verbal or telephone order may be given to a registered nurse. Each verbal

order is dated by the individual taking the order and identifies the names of the individuals

who gave and received it. In such cases, the provider confirms the order, signs, dates, and

stamps it within 48 hours.

5.37.14. Reverse of AF Forms 3068, PRN Medication Administration Record and 3069,

Medication Administration Record.

5.37.14.1. The reverse of these forms contain a section for the initials and signatures of

nursing staff administering the medications. Instead of signing the reverse of these forms,

utilize a separate sheet that contains the names, signatures and initials of the nursing staff.

5.37.14.2. When there is a separate sheet with the names, signatures and initials, the

nursing staff is only required to initial the reverse of the AF Form 3068 and 3069 when

administering medications.

5.37.14.3. File the sheet after the AF Form 3068 or 3069.

5.37.15. Maintain inpatient records received with a transfer-in patient as a component part of,

and attach to, the current inpatient record. Do not break up the transfer record and interfile its

forms among the forms of the current record. Note: If the original record was sent, copy and

maintain the pertinent portions, returning the original record to the transferring MTF.

AFMAN41-210 10 SEPTEMBER 2019 187

5.38. Prenatal Records. Prenatal documentation is maintained in the OB/GYN clinic until the

mother delivers.

5.38.1. If delivery is in the mother’s home MTF, maintain the documents, as a package, with

the inpatient documentation and file in the mother’s inpatient record.

5.38.2. If the delivery was not performed in the MTF, scan and upload the prenatal package

(as a whole package with prenatal treatment documents filed chronologically between the SF

533, Prenatal and Pregnancy Medical Record and AF Form 3915, Labor and Delivery

Flowsheet) in the mother’s electronic health record.

5.39. The Extended Ambulatory Record.

5.39.1. The extended ambulatory record is a folder that contains information on treatment

received during an ambulatory procedure visit, an observation stay, ER Death, Dead on

Arrival, or other similar status.

5.39.1.1. Create records at time of disposition and completion of each episode of care for

future retirement. Ensure discharge summary is scanned/uploaded into approved

electronic health record. Create a separate folder for each episode.

5.39.1.2. Maintain the extended ambulatory record folder in a method similar to the

inpatient record, using the inpatient record folder (AF Form 788A-J, Inpatient Record).

Annotate the folder with the patient’s name, family member prefix, and sponsor’s social

security number. Attach the CHCS Medical Record Tracking bar code label to the folder.

The extended ambulatory record will be filed by the sponsor’s social security number

(same as the outpatient and inpatient records). (T-3).

5.39.1.3. The extended ambulatory record will be maintained in a limited access area.

5.39.1.4. Although the paperwork for these cases is filed in the extended ambulatory

record folder, these episodes are coded as an outpatient episode in the appropriate

ambulatory data collection system.

5.40. Creating, Coding, and Documenting, Ambulatory Procedure Visit Records.

5.40.1. File original documentation on a patient seen during an ambulatory procedure visit

episode in the extended ambulatory record folder.

5.40.2. Create an ambulatory procedure visit record for those cases when a patient is seen in

the ER or specialty procedure room, an ambulatory procedure visit procedure is performed,

and the patient is discharged within 23 hours and 59 minutes of the time the patient was

checked in by the nurse for preliminary work-up for the procedure.

5.40.3. Maintain the record in a limited access area (preferably in the inpatient records

department). The ambulatory procedure visit record will be filed by the sponsor’s social

security number, (same as the outpatient and inpatient records). (T-3).

5.40.4. Clinical Application of Ambulatory Procedure Visit Records.

5.40.4.1. The medical record documentation for the ambulatory procedure visit must meet

the standards of documentation similar to the short-term stay (abbreviated medical record).

(T-1). The record documentation must comply with Joint Commission standards. (T-0).

At a minimum, the record must include an abbreviated history and physical, progress notes,

188 AFMAN41-210 10 SEPTEMBER 2019

doctor’s orders, patient’s informed consent, operative report, tissue report (if any),

anesthesia record, summary of care, to include discharge instructions and any Advance

Directive. (T-2). Copies of the summary, operative report, and any tissue reports are

forwarded to the outpatient record.

5.40.4.2. Physicians will sign and stamp an automated cover sheet or ambulatory

encounter summary form for the ambulatory procedure visit records. All diagnoses and

procedures will be written in full, without symbols or abbreviations, and in acceptable

provider terminology. (T-3).

5.40.4.3. The following forms are recommended for use in ambulatory procedure visit

records:

5.40.4.3.1. AF Form 560 or automated coversheet.

5.40.4.3.2. DD Form 2770.

5.40.4.3.3. SF 509.

5.40.4.3.4. SF 516.

5.40.4.3.5. OF 522, Anesthesia Medical Record or locally produced form.

5.40.4.3.6. OF 517, Request for Administration of Anesthesia and for Performance of

Operations and Other Procedures.

5.40.4.3.7. AF Form 3066 or 3066-1.

5.40.4.3.8. AF Form 3069.

5.40.4.3.9. AF Form 3068.

5.40.4.3.10. AF Form 3067, Intravenous Record.

5.40.4.4. Until Standard, Air Force or DD Forms (for ambulatory procedure visit records)

are developed, each MTF may elect to develop local forms, as an alternative to the

established forms listed in paragraph 5.40.4.3 to integrate documentation requirements into

the comprehensive records. The MTF Medical Records Function approves all requests for

locally developed forms before use in the health record. The MTF may utilize an

ambulatory encounter summary form.

5.40.5. Coding of Ambulatory Procedure Visits.

5.40.5.1. Code diagnoses according to current version of the International Classification

of Diseases (ICD) or current government approved coding classification system.

5.40.5.2. Code procedures/operations according to Current Procedure Terminology

coding references or current government approved coding classification system.

5.40.5.3. Utilize the Ambulatory Data Module in CHCS to capture the coded information

on each ambulatory procedure visit.

5.40.5.4. Utilize the Ambulatory Data Module Patient Encounter Forms or the automated

ambulatory procedure visit form used for coding in the ambulatory procedure visit record

for auditing and quality assurance purposes.

5.40.6. Admission of Ambulatory Procedure Visit Patients.

AFMAN41-210 10 SEPTEMBER 2019 189

5.40.6.1. Admit as an inpatient an ambulatory procedure visit patient that stays beyond the

time limit of 23 hours and 59 minutes. Time commences when the patient is checked in

for preliminary work-up for the procedure.

5.40.6.2. Do not backdate or change the time of the admission date and time to the point

when the patient’s ambulatory procedure visit episode began. Use the date and time when

the admission to the hospital occurs. Enter the following statement in the administrative

section of the cover sheet “Patient admitted from APU. Information on the ambulatory

procedure visit procedure is maintained in the ambulatory procedure visit record.”

5.40.6.3. Do not combine the original ambulatory procedure visit documentation with the

inpatient record but maintain it separately in the extended ambulatory record folder.

5.40.6.4. Include copies of the Ambulatory Data Module Patient Encounter Form or

automated cover sheet, the abbreviated history and physical, operative report, and any other

pertinent documentation in the inpatient record, as applicable.

5.40.6.5. Code the inpatient record with the reason that caused the admission.

5.41. Creating, Coding, and Documenting Observation Records.

5.41.1. Observation patients are outpatients with acute or chronic medical problems who

require assessment monitoring or diagnostic evaluation in order to determine final disposition.

The decision to place a patient in observation status is based upon the complexity, intensity,

and duration of care required as determined by the provider.

5.41.2. Outpatient observation stays generally should not exceed 23 hours and 59 minutes.

However, up to 48 hours may be authorized when medical necessity has been clearly

demonstrated.

5.41.3. Observation patients may be cared for in either dedicated observation units or in any

designated bed space. Appropriate Joint Commission standards will apply. (T-3).

5.41.4. Documentation of Observation Records.

5.41.4.1. Documentation for an observation patient must meet the standards for a short-

term stay (abbreviated medical record) and must comply with the current Joint Commission

documentation standards. (T-3).

5.41.4.2. SFs, or other forms as noted, are recommended for use in observation records.

At a minimum, the documentation in the medical record will include:

5.41.4.2.1. Summary of pertinent diagnostic findings.

5.41.4.2.2. A plan of care to include reasons for observation, diagnoses, and risks of

complication, patient education, release instructions, medication orders, and plans for

follow-up care.

5.41.4.2.3. SF 558.

5.41.4.2.4. SF 509.

5.41.4.2.5. All diagnostic reports (e.g., laboratory, radiology, or electrocardiogram) as

applicable.

5.41.4.2.6. AF Form 3066 or 3066-1.

190 AFMAN41-210 10 SEPTEMBER 2019

5.41.4.2.7. AF Form 3069 as applicable.

5.41.4.2.8. AF Form 3068 as applicable.

5.41.4.2.9. AF Form 3067 as applicable.

5.41.4.2.10. Advance Directive (if previously accomplished by the patient).

5.41.4.3. File all documentation related to an observation stay in the extended ambulatory

record folder.

5.41.4.4. Forward the following documents to the outpatient treatment record: release note

with summary of pertinent diagnostic findings, status of patient upon release, and release

instructions with plans for follow-up care.

5.41.5. Coding of Observation Records.

5.41.5.1. Code diagnoses according to the current version of the ICD coding references or

current government approved coding classification system.

5.41.5.2. Code procedures/operations according to the Current Procedural Terminology

coding references or current government approved coding classification system.

5.41.5.3. Utilize the Ambulatory Data Module in CHCS to capture the coded information

on each observation episode, except when an observation patient is admitted.

5.41.6. Admission of Observation Patients. When a patient is admitted from an observation

status, file the observation documentation in the extended ambulatory record folder. Place

copies of pertinent documentation in the inpatient record.

5.42. Patients Discharged Without Definitive Diagnosis. The inpatient records department

maintains in a suspense file, records that the provider has indicated should be held pending

pathology reports, laboratory test results, or other confirmations. Never maintain the records in

suspense longer than one month after the month of disposition. (T-1). Process the record with

whatever information is available. The record may be corrected at a later date if information,

which alters the final diagnosis, is received.

5.43. Disposition of Inpatient Records.

5.43.1. When transferring patients to another MTF, send a complete and legible copy of the

current inpatient record, original outpatient record, and copies of any previous admissions

pertinent to the patient’s current condition. If complete and legible copies cannot be made in

time for the patient’s transfer, send the original current inpatient record. Note: The receiving

MTF returns original records to the transferring MTF when they have served their purpose.

Also, send any x-ray films and duplicate slides or surgical specimens when the findings have

a direct bearing on the diagnosis and treatment.

5.43.2. The admitting facility notifies the originating MTF of patients admitted while on

directed convalescence, PCS home, or Absent Without Leave (AWOL) from another medical

facility while in patient status. If the patient will remain at the new MTF, the initial facility

transfers the individual to the new MTF and forwards the patient’s records.

5.43.3. When transferring patients to non-military MTFs, a transcript or copy of pertinent

pages may accompany the patient. Never release the original records; however, pertinent x-

ray films are furnished to the receiving non-military MTF as required.

AFMAN41-210 10 SEPTEMBER 2019 191

5.43.4. Send a copy of the current inpatient record and any x-ray films when an AD patient is

transferred to a VA hospital pending separation or retirement from the uniformed services.

5.43.5. Forward original records of NATO military personnel and their family members

(including x-ray film and medical examination reports) in a sealed envelope with the individual

concerned upon transfer to another MTF. When the individual is discharged, return the record

to the parent country. Retain copies of pertinent records necessary for quality assurance

review.

5.43.6. Handle inpatient records of non-NATO military personnel and their family members

the same as any other inpatient record.

5.43.7. When mailing records pertinent to litigation cases, mail medical records and claims

files via certified mail/return receipt.

5.44. Medical Transcription.

5.44.1. Responsibilities of Medical Transcription: Medical transcription services provide

timely and accurate transcription of provider dictation dealing with inpatient and ambulatory

patient care. It is a patient administration responsibility and is usually managed by the inpatient

medical records department supervisor in cooperation with the transcription quality assurance

evaluator and/or contracting officer’s technical representative.

5.44.2. Production Goals: Each medical transcription center should produce an acceptable

quantity and quality of medical transcription in a timely manner. Normally, these services are

employed to generate transcription services for inpatient episodes of care. If transcription

staffing and inpatient workload allow, transcription services can be expanded to ambulatory

and outpatient clinic services. Inpatient and ambulatory procedure visits dictated operative

reports must be transcribed and filed in the medical record immediately following surgery. (T-

3). In accordance with The Joint Commission, MTFs must generate clear policy/guidance to

all providers in their facility regarding the scope of medical transcription services they intend

to offer. (T-3).

5.44.2.1. Quantity: Suggested production goals for medical transcriptionist are 800 lines

per day per transcriptionist. The senior transcriptionist or supervisor, in a smaller medical

transcription center, contributes to the work center output; however, their goals are lower

than those established for other medical transcriptionists and decrease as the size of the

medical transcription center and supervisory responsibilities increase. Personnel in

training should be able to achieve the production goals within a reasonable period of time,

not to exceed 1 year.

5.44.2.2. Counting and Reporting: Medical transcriptionists count and record their output

according to the following suggested instructions. (Output is reported daily to the senior

transcriber or supervisor)

5.44.2.2.1. Margins should be adjusted to ensure full lines that average 80 strokes.

Narrative lines of 80 strokes should average 13 words. Count each typed line with six

words or more as a line; any narrative line with five words or less is not counted.

5.44.2.2.2. Form-style typing:

5.44.2.2.2.1. Count each line with two or more names, dates or words as one line.

192 AFMAN41-210 10 SEPTEMBER 2019

5.44.2.2.2.2. Physician signature elements are counted as two lines when a two-

line signature element is used, and counted as one line when a one-line signature

element is used.

5.44.2.2.2.3. Patient identification data is counted as two lines.

5.44.2.2.3. The senior transcriptionist or supervisor reports individual production to

the supervisor or Quality Assurance Evaluator/Contracting Officer’s Technical

Representative of inpatient records.

5.44.2.3. The supervisor or Quality Assurance Evaluator/Contracting Officer’s Technical

Representative of inpatient records, through the senior transcriptionist or supervisor,

monitors the quality of all medical transcription. When medical transcriptionists are

required to retype work which does not meet quality standards, do not include lines retyped

in production counts.

5.44.2.4. Work should normally be completed within 24 hours of receipt of dictation.

Transcribed narrative summaries and operative reports should be filed in the medical

record prior to inpatient/ambulatory procedure visit coding to provide complete

documentation and ensure accurate coding.

Section 5D—Deployed Assignment Medical Record Management

5.45. Minimum Deployed Medical Documentation and Record Management Requirements.

5.45.1. Unless exempted by COCOM/Component reporting instructions, the DD Form 2766is

the principle folder used to document primary medical and dental care for AD, AFR, ANG,

and deployed federal civilian employees. Inpatient documents generated from a theater MTF

will likely be maintained and documented separately from the medical information stored in

the DD Form 2766.

5.45.2. Health records located at deployed combat theater locations are maintained by unit

medical personnel. Deployed medical commanders will ensure effective re-deployment

medical out-processing procedures are in place, and will work with deployed unit commanders

to ensure required actions are completed for all re-deploying personnel, to include all DoD

uniformed members, civilians, and contractors in accordance with DoDI 6490.03, AFI 10-403,

Deployment Planning and Execution, and AFI 48-122, Deployment Health. (T-0).

5.45.3. Unless exempted by the COCOM/Component reporting instructions, deployed

medical unit records managers will use the cardstock DD Form 2766 to document primary

medical and dental care. (T-0). Reference DoDI 6490.03. Deployed records personnel are

required to file all primary local, Service-specific, SFs, and OFs generated from primary care

provider-patient encounters, into the cardstock DD Form 2766. (T-0). Reference DoDI

6490.03. File documents inside the cardstock DD Form 2766 in chronological order, with the

most recent encounter filed on top of older documents.

5.45.4. Theater Electronic Health Records and/or Applications: Although advances in

electronic medical record technology support comprehensive regional healthcare operations in

the deployment environment, unless the medical information maintained in these systems can

provide reliable, secure, and timely medical record data transfer from the deployed medical

unit to the DoD’s Central Data Repository, or otherwise exempted by COCOM/Component

AFMAN41-210 10 SEPTEMBER 2019 193

reporting instructions, deployed medical records personnel are required to print each primary

care patient encounter and file the printed form into the cardstock DD Form 2766.

5.45.5. Documenting Patient Care: Proper documentation of medical/surgical care is

accomplished on all patients treated at the Expeditionary Medical Support/Air Force Theater

Hospital. Utilization of the SF 600, is the primary form used to document most ambulatory

care. AF Form 3910, Critical Care Flow Sheet (Small MTF) is used to record critical care

patients’ treatment/progress. All ambulatory care healthcare forms and documents must be

filed into the DD Form 2766. (T-0). Reference DoDI 6490.03. The outpatient healthcare

information collected on these forms must return to the member’s host MTF. (T-0). Reference

DoDI 6490.03.

5.45.5.1. For patients entering the aeromedical evacuation system, the AF Form 3830,

Patient Manifest (5 copies minimum) should be completed for each Aeromedical

Evacuation mission. If not available, substitute this form with the DD Form 601, Patient

Evacuation Manifest. The AF Form 3899, Aeromedical Evacuation Patient Record,

accompanies the patient to ensure appropriate care during transport. This document is

primarily used to direct and record en route care. If AF Form 3899 is not available, use

DD Form 602, Patient Evacuation Tag. Medical orders should be clearly written on either

the AF Form 3899 or the DD Form 1380, Tactical Combat Casualty Care (TCCC) Card.

The DD Form 1380 normally is used by the originating facility during contingencies. The

information on the DD Form 1380 is transcribed to the AF Form 3899/DD Form 602 upon

entry into the Aeromedical Evacuation System. Information should include both primary

and secondary diagnoses, correct patient classification, and orders for all enroute

medications, care, and special diets. A concise, pertinent nursing note from the referral

MTF should be written on the form as a transfer note. At a minimum, the note should

include the dates and times of last medications, vital signs, and treatment rendered.

5.45.5.2. Required deployed healthcare minimum documentation forms include (T-1): SF

Form 600; DD Form 1380; DD Form 2992; AF Form 422; AF Form 579, Controlled

Substances Register; SF 516, OF 517; and DD Form 599, Patient’s Effects Storage Tag.

5.45.6. Deployed MTF medical staff will:

5.45.6.1. Conduct redeployment processing in accordance with DoDI 6490.03, AFI 10-

403 and AFI 48-122. Work with the deployed Military Personnel Section and unit

commanders to ensure all returning or re-deploying personnel are identified in a timely

manner and have completed medical re-deployment screening and/or out-processing no

earlier than 30 days prior to scheduled/projected departure.

5.45.6.2. If required, conduct DD Form 2796, Post-Deployment Health Assessment, in

accordance with Air Force Instruction 48-122.

5.45.6.3. Complete DD Form 2796 electronically via ASIMS. Hard copy forms will not

be accepted.

5.45.6.4. A legible copy of the DD Form 2796 must be documented in the deployer’s

electronic health record, if the capability exists. (T-0). Otherwise, MTF medical personnel

are required to print a hard copy of the electronic DD Form 2796 and place it in the

member’s deployment medical record (DD Form 2766). (T-2). For more specific

instructions for ASIMS/AHLTA documentation, see AFI 48-122.

194 AFMAN41-210 10 SEPTEMBER 2019

5.45.6.5. If the deployer is unable to complete the form electronically due to computer

failure, network interruption, or the unavailability of an automated process, deployed

medical staff must prominently place the following notice in the DD Form 2766; “Member

unable to Electronically Complete DD Form 2796 in Theater. (T-3). Member must report

to Public Health within 5 duty days of returning to home unit to complete the electronic

DD Form 2796.” (T-2).

5.45.7. Deployed MTF support (records) staff will (T-1):

5.45.7.1. File the signed/stamped hard copy DD Form 2796 into the DD Form 2766 for

later transcription into ASIMS and documentation in AHLTA by a host station MTF

provider, when the location does not have electronic health record capability.

5.45.7.2. Package and seal the medical records for each returning service member.

Individual records may be bundled together (but not inter-filed) and sealed together in a

bulk courier package. Identify the troop commander for each returning or re-deploying

group and transfer the sealed medical records to the troop commander. If no troop

commander exists, identify the senior ranking member in the group and transfer the records

to the ranking member, or authorized delegate. Obtain a chain of custody receipt before

completing the transfer. If records are to be packaged and sealed for a single returning or

re-deploying service member, first check with a mental health provider to ensure the

service member should not be physically or mentally harmed if the member were to open

the sealed package and read the documents inside. If the mental health provider decides

the sealed medical documents for a returning or re-deploying service member could

potentially cause harm if the member were to read the documents, contact the service

member’s host MTF and arrange for the records to be mailed back to the medical unit. If

the mailing option is used, ensure the package is mailed with a package-tracking or return-

receipt confirmation service (if available).

5.45.7.3. Each DD Form 2766 should contain all primary care medical documents

generated during the length of the deployment. The minimum number and name of

documents to be filed into each DD Form 2766 include:

5.45.7.3.1. Smallpox vaccination screening forms (SF 600 Overprint).

5.45.7.3.2. All primary care patient documents (if no automated data transfer

mechanism exists that guarantees reliable, secure, and timely medical record data

transfer from the deployed location to DoD’s Central Data Repository, print each

primary care patient encounter and file the printed form into the cardstock DD Form

2766).

5.45.7.3.3. Environmental/Occupational Health Exposure Data (SF 600 Overprint).

5.45.7.3.4. Physical therapy and dental visit records.

5.45.7.3.5. Mental health provider documentation: (Note: If a mental health provider

decides that sealed medical documents for a returning or re-deploying service member

could potentially cause harm if the member were to read the documents, contact the

service member’s host MTF and arrange for the records to be mailed back to the

medical unit).

5.45.7.3.6. Provider signed, dated, and Identification stamped DD Form 2796.

AFMAN41-210 10 SEPTEMBER 2019 195

5.45.7.3.7. Insert a shipping roster of names and ranks for each corresponding DD

Form 2766 placed inside each bulk courier package. Label individual sealed envelopes

with the returning or re-deploying member’s name, rank, home unit, and assignment

installation. For bulk courier and individual medical record packages, address the

outside envelope or package with the following pre-printed or stamped message, “PHI

ENCLOSED. THIS ENVELOPE MUST BE DELIVERED TO THE FORCE

HEALTH MANAGEMENT OFFICE AT YOUR HOME DUTY STATION.”

5.46. Expeditionary Electronic Health Record Management Platforms and Systems. A

complete list of expeditionary electronic health record management platforms and systems can be

found at the Defense Health Clinical Systems website: https://www.health.mil/.

5.47. Emergency Medical Service and AF Form 552, Air Force Patient Care Report.

5.47.1. Patients transported to a MTF for care/treatment/admission. If the patient is

transported to the MTF, the information on the AF Form 552 is relevant to their care. The

healthcare provider should include the AF Form 552 as part of the patient's health record.

5.47.1.1. A copy should be sent to the Medical Director for peer review and a copy to

TRICARE Operations and Patient Administration for billing considerations.

5.47.1.2. Copies should be retained in accordance with normal retention standards.

5.47.2. Patients transported to a non-DoD facility with existing record. If the patient is

empaneled to the MTF or otherwise has an existing record (e.g., occupational health record)

the AF Form 552 is relevant to their care and should be included as part of the patient’s health

record.

5.47.2.1. A copy should be sent to the Medical Director for peer review and a copy to

TRICARE Operations and Patient Administration for billing considerations.

5.47.2.2. Copies should be retained in accordance with normal retention standard.

5.47.3. Patients transported to DoD facility (non-beneficiary). Due to legal and liability

considerations, maintain a copy of the AF Form 552 for a minimum of two years. If the patient

is not a beneficiary, the form can be kept in an alphabetical file and maintained similar to

AFRIMS rule T41-08 R 09.00 https://afrims.cce.af.mil/afrims/rims.cfm.

5.47.4. Any copies of the AF Form 552 provided to or used by other areas of the MTF, as

deemed appropriate by the Medical Director, should be maintained in accordance with existing

retention standards.

DOROTHY A. HOGG

Lieutenant General, USAF, NC

Surgeon General

196 AFMAN41-210 10 SEPTEMBER 2019

Attachment 1

GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION

References

5 CFR Part 339.301, Authority to Require an Examination, 18 January 2017

32 CFR Part 199, Civilian health and Medical Program of the Uniformed Services (CHAMPUS),

1 July 1986

42 CFR Part 493, Laboratory Requirements, 14 March 1990

45 CFR Part 164, Security and Privacy, 28 December 2000

5 USC § 552a, User Training for TRANSCOM Reporting and Command & Control Evacuation

System (TRAC2ES), 16 March 2018

5 USC § 8103, Medical Services and Initial Medical and Other Benefits, 19 May 2019

5 USC § 8141, Civil Air Patrol Volunteers, 15 August 1994

5 USC § 8142, Peace Corps Volunteers, 9 October 2018

5 USC § 8143, Job Corps Enrollees, Volunteers in Service to America, 21 September 1993

10 USC § 1072, Definitions, 12 December 2017

10 USC § 1074, Medical and Dental Care for Members and Certain Former Members, 12

December 2017

10 USC § 1074b, Medical and Dental Care: Academy Cadets and Midshipmen; Members of,

and Designated Applicants for Membership in, Senior ROTC, 28 October 2004

10 USC § 1074h, Medical and Dental Care: Medal of Honor Recipients; Dependents, 13

August 2018

10 USC § 1076, Medical and Dental for Dependents: General Rule, 28 December 2001

10 USC § 1095, Healthcare Services Incurred on Behalf of Covered Beneficiaries: Collection

From Third Party Payers, 30 November 1993

10 USC § 1210, Members on Temporary Disability Retired List: Periodic Physical

Examination; Final Determination of Status, 23 December 2016

10 USC § 1588, Authority to Accept Certain Voluntary Services, 19 December 2014

24 USC § 34, Hospitalization of Persons Outside Continental Limits of United States; Persons

Entitled; Availability of Other Facilities; Rate of Charges; Disposition of Payments, 26 October

2015

37 USC § 310, Special Pay: Duty Subject to Hostile Fire or Imminent Danger, 2 January 2013

38 USC § 1720G, Assistance and support for caregivers, 29 September, 2018

National Defense Authorization Act for Fiscal Year 2019, Section 711, Transition of

Administration by Defense Health Agency of Military Medical Treatment Facilities, 15 May,

2018

AFMAN41-210 10 SEPTEMBER 2019 197

DFAS DEM 177-373, Department of Defense (DoD) Financial Management Regulation,

February 1999

DHA IPM 18-001, Standard Appointing Processes, Procedures, Hours of Operation,

Productivity, Performance Measures and Appointment Types in Primary, Specialty, and

Behavioral Health Care in Medical Treatment Facilities (MTFs), 3 July 2018

DHA IPM 18-016, Medical Coding of the DoD Health Records, 19 October, 2018

DHA IPM 18-018, Physical Custody and Control of the DoD Health Record, 8 November 2018

DoDI 1000.13, Identification (ID) Cards for Members of the Uniformed Services, Their

Dependents, and Other Eligible Individuals, 23 January 2014

DoDI 1000.30, Reduction of Social Security Number (SSN) Use Within DoD, 1 August 2012

DoDI 1241.01, Reserve Component (RC) Line of Duty Determination for Medical and Dental

Treatments and Incapacitation Pay Entitlements, 19 April 2016

DoDI 1332.18, Disability Evaluation System, 5 August 2014

DoDI 1341.02, Defense Enrollment Eligibility Reporting System (DEERS) Program and

Procedures, 8 August 2016

DoDI 1342.24, Transitional Compensation for Abused Dependents, 23 May 1995

DoDI 1400.32, DoD Civilian Work Force Contingency and Emergency Planning Guidelines and

Procedures, 24 April 1995

DoDI 3020.41, Operational Contract Support (OCS), 20 December 2011

DoDI 5154.30, Armed Forces Medical Examiner System (AFMES) Operations, 29 December

2015

DoDI 6000.11, Patient Movement, 22 June 2018

DoDI 6000.14, DoD Patient Bill of Rights and Responsibilities in the Military Health System

(MHS), 26 September 2011

DoDI 6015.23, Foreign Military Personnel Care and Uniform Business Offices in Military

Treatment Facilities (MTFs), 23 February 2015

DoDI 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the

Military Health System (MHS), 17 February 2011

DoDI 6025.23, Health Care Eligibility Under the Secretarial Designee (SECDES) Program and

Related Special Authorities, 16 September 2011

DoDI 6040.40, Military Health System Data Quality Management Control Procedures, 26

November 2002

DoDI 6040.42, Management Standards for Medical Coding of DoD Health Records, 8 June 2016

DoDI 6040.45, DoD Health Record Life Cycle Management, 16 November 2015

DoDI 6200.06, Periodic Health Assessment (PHA) Program, 8 September 2016

DoDI 6465.03, Anatomic Gifts and Tissue Donation, 8 June 2016

198 AFMAN41-210 10 SEPTEMBER 2019

DoDI 6490.03, Deployment Health, 11 August 2006

DoDI 6490.12, Mental Health Assessments for Service Members Deployed in Connection with a

Contingency Operation, 26 February 2013

DoD 7750.07-M, DoD Forms Management Program Procedures Manual, 7 May 2008

DoD 5400.11-R, Department of Defense Privacy Program, 14 May 2007

DoDM 6025.18, Implementation of the Health Insurance Portability and Accountability Act

(HIPAA) Privacy Rule in DoD Health Care Programs, 13 March 2019

DoDM 5210.42, Nuclear Weapons Personnel Reliability Program, 13 January 2015

AFI 10-203, Duty Limiting Conditions, 20 November 2014 AFI 10-403, Deployment Planning

and Execution, 20 September 2012

AFI 16-108, Managing the Aviation Leadership Program, 17 August 2015

AFI 31-105, The Air Force Corrections System, 15 June 2015

AFI 33-332, Air Force Privacy and Civil Liberties Program, 12 January 2015

AFI 33-360, Publications and Forms Management, 1 December 2015

AFI 34-1101, Warrior and Survivor Care, 6 May 2015

AFI 34-501, Mortuary Affairs Program, 16 April 2019

AFI 36-2110, Total Force Assignments, 5 October 2018

AFI 36-2603, Air Force Board for Correction of Military Records (AFBCMR), 18 September

2017

AFI 36-2608, Military Personnel Records Systems, 26 October 2015

AFI 36-2910, Line of Duty Misconduct Determination, 8 October 2015

AFI 36-3002, Casualty Services, 26 April 2019

AFI 36-3003, Military Leave Program, 11 May 2016

AFI 36-3024, Transitional Compensation for Abused Dependents, 24 January 2018

AFI 36-3026V1_IP, Identification Cards for Members of the Uniformed Services, Their Eligible

Family Members, and Other Eligible Personnel, 4 Aug 2017

AFI 36-3208, Administrative Separation of Airman, 9 July 2004

AFI 36-3212, Physical Evaluation for Retention, Retirement, and Separation, 2 February 2006

AFI 40-301, Family Advocacy Program, 16 November 2015

AFI 40-701, Medical Support to Family Member Relocation and Exceptional Family Member

Program (EFMP), 19 November 2014

AFI 41-106, Medical Readiness Program Management, 9 June 2017

AFI 41-126, DoD/Veterans Affairs Health Care Resource Sharing Program, 4 September 2018

AFI 41-200, Health Insurance Portability and Accountability Act (HIPAA), 25 July 2017

AFMAN41-210 10 SEPTEMBER 2019 199

AFI 44-102, Medical Care Management, 17 March 2015

AFI 44-110, The Cancer Program, 18 September 2014

AFI 44-119, Medical Quality Operations, 16 August 2011

AFI 44-121, Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program, 18 July

2018

AFI 44-172, Mental Health, 13 November 2015

AFI 44-176, Access to the Care Continuum, 8 September 2017

AFI 48-122, Deployment Health, 18 August 2014

AFI 48-123, Medical Examinations and Standards, 5 November 2013

AFI 48-307V1, En Route Care and Aeromedical Evacuation Medical Operations, 9 January

2017

AFI 90-1001, Planning Total Force Association (TFAS), 9 January 2017

AFI 90-6001, Sexual Assault Prevention and Response (SAPR) Program, 21 May 2015

AFI 91-204, Safety Investigation and Reports, 27 April 2018

AFMAN 33-363, Management of Records, 1 March 2008

AFMAN 65-605V1_AFGM2018-01, Budget Guidance and Technical Procedures, 24 October

2018

AFMAN 65-116V1, Defense Joint Military Pay System Active Component (DJMS-AC) FSO

Procedures, 1 April 2007

AFPD 10-29, Worldwide Aeromedical Evacuation Operations, 13 February 2019

AFPD 41-2, Medical Support, 17 May 2018

AR 40-562/BUMEDINST 6230.15B /AFI 48-110/CG COMDTINST M6230.4G, Immunizations

and Chemoprophylaxis for the Prevention of Infectious Diseases, 7 October 2013

Headquarters Air Force Mission Directive 1-6, Administrative Assistant to the Secretary of the

Air Force, 22 December, 2014

Headquarters Air Force Mission Directive 1-48, The Air Force Surgeon General, 7 May 2015

Headquarters Air Force Mission Directive 1-24, Special Management, 28 January, 2019

Health Affairs Policy 05-014, Policy Guidance for Enrollment of AD Service Members into

TRICARE Prime, 19 August 2005, https://www.health.mil/Reference-Center/Policies

Health Affairs Policy 08-002, Policy for Billing Care Furnished by MTFs to Federal Employees

for On-the-Job Injuries and for Occupational Health, 26 March 2008,

https://www.health.mil/Reference-Center/Policies

Health Affairs Policy 11-005, TRICARE Policy for Access to Care, 23 February 2011,

https://www.health.mil/Reference-Center/Policies

200  AFMAN41-210  10 SEPTEMBER 2019 
Health Affairs Policy Memorandum 99-003, Physical Examinations for Reserve Officer Training 
Corps (ROTC) Applicants, 18 December 1999, https://www.health.mil/Reference-
Center/Policies 
Joint Travel Regulations, https://www.dfas.mil/militarymembers/travelpay/regulations.html 
Medical Department (MANMED), NAVMED P-117, Chapter 16, Health Records, 23 December 
1994, https://www.med.navy.mil/directives/Pages/BUMEDInstructions.aspx 
Medical Record Tracking, Retirement and Retrieval User Guide, 
https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx 
MHS, Patient Identity Management and Registration Guidance, 28 October 2013, 
https://www.health.mil/ 
MHS, Notice of Privacy Practices, 1 October 2013 https://www.health.mil/ 
The Joint Commission, 
https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx 
TRICARE Policy Manual 6010.60-M, Chapter 4, Section 16.1, Intersex Surgery, 1 April 2015 
https://www.health.mil/ 
Prescribed Forms 
AF Form 146, Death Tag 
AF Form 230, Request for Patient Transfer 
AF Form 250, Health Record Charge Out Request 
AF Form 552, Air Force Patient Care Report 
AF Form 560, Authorization and Treatment Statement 
AF Form 565, Record of Inpatient Treatment 
AF Form 570, Notification of Patient’s Medical Status 
AF Form 577, Patient’s Clearance Record 
AF Form 614, Charge Out Record 
AF Form 788A-J, Inpatient Record 
AF Form 1403, Roster of Seriously Ill/Very Seriously Ill 
AF Form 1480, Summary of Care (Canceled) 
AF Form 1480A, Adult Preventive and Chronic Care Flowsheet 
AF Form 1480B, Adult Preventive and Chronic Care Flowsheet Continuation Sheet 
AF Form 2100A, Health Record - Outpatient  
AF Form 2100B, Health Record - Dental 
AF Form 2110A, Health Record - Outpatient 
AF Form 2120A, Health Record - Outpatient 

AFMAN41-210 10 SEPTEMBER 2019 201

AF Form 2130A, Health Record - Outpatient

AF Form 2140A, Health Record - Outpatient

AF Form 2150A, Health Record - Outpatient

AF Form 2160A, Health Record - Outpatient

AF Form 2170A, Health Record - Outpatient

AF Form 2180A, Health Record - Outpatient

AF Form 2190A, Health Record - Outpatient

AF Form 3066, Doctor’s Orders

AF Form 3066-1, Doctor’s Orders

AF Form 3068, PRN Medication Administration Record

Adopted Forms

AF Form 40A, Record of Individual Inactive Duty Training

AF Form 100, Request and Authorization for Separation

AF Form 330, Records Transmittal/Request

AF Form 348, Line of Duty Determination

AF Form 348-R, Line of Duty Determination for Restricted Report of Sexual Assault

AF Form 422, Notification of Air Force Member’s Qualification Status

AF Form 469, Duty Limiting Condition Report

AF Form 579, Controlled Substances Register

AF Form 745, Sensitive Duties Program Record Identifier

AF Form 797, Job Qualification Standard Continuation/Command JQS

AF Form 885, Medical Record Charge Out Guide (Red) (For use by USAF Medical Treatment

Facilities ONLY)

AF Form 886, Medical Record Charge Out Guide (Yellow) (For use by USAF Medical

Treatment Facilities ONLY)

AF Form 887, Medical Record Charge Out Guide (Blue) (For use by USAF Medical Treatment

Facilities ONLY)

AF Form 847, Recommendation for Change of Publication

AF Form 1122, Personal Property and Personal Effects Inventory

AF Form 1185, AF Form 1185, Commander’s Impact Statement for Medical Evaluation Board

AF Form 1288, Application for Ready Reserve Assignment

AF Form 1418, Recommendation for Flying or Special Operation Duty - Dental

AF Form 1488, Daily Log of Patients Treated for Injuries

202 AFMAN41-210 10 SEPTEMBER 2019

AF Form 1942, Clinic Index

AF Form 2005, Issue/Turn-In-Request

AF Form 2700L, Health Record Year Grid

AF Form 3067, Intravenous Record Medical/Dental Records or Information

AF Form 3069, Medication Administration Record

AF Form 3830, Patient Manifest

AF Form 3899, Aeromedical Evacuation Patient Record

AF Form 3910, Critical Care Flow Sheet (Small MTF)

AF Form 3915, Labor and Delivery Flowsheet

DD Form 137-5, Dependency Statement

DD Form 214, Certificate of Release or Discharge from Active Duty

DD Form 261, Report of Investigation Line of Duty and Misconduct Status

DD Form 599, Patient’s Effects Storage Tag

DD Form 601, Patient Evacuation Manifest

DD Form 602, Patient Evacuation Tag

DD Form 689, Individual Sick Slip

DD Form 877-1, Request for Medical/Dental Records from the National Personnel Records

Center (NPRC) (St. Louis, Missouri)

DD Form 1380, Tactical Combat Casualty Care (TCCC) Card

DD Form 2005, Privacy Act Statement - Healthcare Records

DD Form 2064, Certificate of Death (Overseas)

DD Form 2138, Request for Transfer of Outpatient Records

DD Form 2499, Health Care Practitioner Action Report

DD Form 2766, Adult Preventive and Chronic Care Flowsheet

DD Form 2766C, Adult Preventive and Chronic Care Flowsheet (Continuation Sheet)

DD Form 2770, Abbreviated Medical Record

DD Form 2796, Post-Deployment Health Assessment

DD Form 2825, Internal Receipt

DD Form 2870, Authorization for Disclosure of Medical or Dental Information

DD Form 2882, Pediatric and Adolescent Preventive and Chronic Care Flowsheet

DD Form 2992, Medical Recommendation for Flying or Special Operational Duty

DoL Form LS-1, Request for Examination and/or Treatment

DoL Form LS-201, Notice of Employee’s Injury or Death

AFMAN41-210 10 SEPTEMBER 2019 203

DoL Form LS-202, Employer’s First Report of Injury or Occupational Illness

DS-2029, Application for Consular Report of Birth Abroad of a Citizen of the United States of

America

Form Compensation Act (CA)-16, Authorization for Examination and/or Treatment

FS-240, Consular Report of Birth

OF 275, Medical Record Report

OF 517, Request for Administration of Anesthesia and for Performance of Operations and Other

Procedures

OF 522, Anesthesia Medical Record

OF 523B, Medical Record – Authorization for Tissue Donation

SF 66D, Employee Medical Folder

SF 93, Report of Medical History

SF 135, Records Transmittal and Receipt

SF 502, Medical Record – Narrative Summary (Clinical Resume)

SF 503, Medical Record-Autopsy Protocol

SF Form 504, Clinical Record-History Parts I and II

SF 505, Medical Record – History Parts 2 and 3

SF 506, Medical Record – Physical Examination

SF 509, Medical Record – Progress Report

SF 516, Operation Report

SF 523, Medical Record-Authorization for Autopsy

SF 526, Medical Record – Interstitial/Intercavitary Therapy

SF 535, Medical Record - Newborn

SF 551, Medical Record – Serology

SF 558, Medical Record – Emergency Care and Treatment

SF 559, Medical Record – Allergen Extract Prescription – New and Refill

SF 600, Chronological Record of Medical Care

VA Form 21-0819, DoD Referral to Integrated Disability Evaluation System (IDES)

VA Form 9957, ACRS Time Sharing Request Form

Abbreviations and Acronyms

AAC—Assignment Availability Code

AD—Active Duty

ADAPT—Alcohol and Drug Abuse Prevention and Treatment

204 AFMAN41-210 10 SEPTEMBER 2019

AFI—Air Force Instruction

AFMOA—Air Force Medical Operations Agency

AFMS—Air Force Medical Service

AFMSA—Air Force Medical Support Agency

AFOSI—Air Force Office of Special Investigation

AFR—Air Force Reserve

AFRC—Air Force Reserve Command

AFRIMS—Air Force Records Information Management System

AFSC—Air Force Specialty Code

AHLTA—Armed Forces Health Longitudinal Technology Application

AMTU—Airman Medical Transition Unit

ANG—Air National Guard

ARC—Air Reserve Component

ASD—Assistant, Secretary of Defense

ASIMS—Aerospace Services Information Management System

AWOL—Absent Without Leave

CED—Contingency, Exercise, Deployment

CHCS—-Composite Healthcare System

CLIA—Clinical Laboratory Improvements Amendments

COCOM—Combatant Command

CONUS—Continental United States

DC—Dental Corps

DEERS—Defense Enrollment Eligibility Reporting System

DHA—Defense Health Agency

DoD—Department of Defense

DoDD—Department of Defense Directive

DoDI—Department of Defense Instruction

DoDM—Department of Defense Manual

DSN—Defense Switched Network

EFMP—Exceptional Family Member Program

ER—Emergency Room

FOIA—Freedom of Information Act

AFMAN41-210 10 SEPTEMBER 2019 205

GSU—Geographically Separated Unit

HAIMS—Health Artifact and Image Management System

HIPAA—Health Insurance Portability and Accountability Act

HIV—Human Immunodeficiency Virus

IG—Inspector General

Kx—Knowledge Exchange

MAJCOM—Major Command

MC—Medical Corps

MDG—Medical Group

MDSS—Medical Support Squadron

MHS—Military Health System

MTF—Military Treatment Facility

NATO—North Atlantic Treaty Organization

NC—Nurse Corps

NCO—-Non-Commissioned Officer

OCO—Overseas Contingency Operations

OCONUS—Outside Continental United States

OSD—Office of the Secretary of Defense

PAS—Personnel Accounting Symbol

PCA—Permanent Change of Assignment

PCS—Permanent Change of Station

PHI—Protected Health Information

PME—Professional Military Education

RC—Reserve Component

RMO—Resource Management Office

ROTC—Reserve Officer Training Corps

SAF—Secretary of the Air Force

SAF/MR—Assistant Secretary of the Air Force for Manpower and Reserve Affairs

SAPR—Sexual Assault Prevention and Response

SECAF—Secretary of the Air Force

SES—Senior Executive Service

SF—Standard Form

206 AFMAN41-210 10 SEPTEMBER 2019

SM—Service Member

SNCO—Senior Non-commissioned Officer

TOL—Tricare Online

TRAC2ES—TRANSCOM Regulating and Command & Control Evacuation System

USC—United States Code

VA—Veterans Affairs

Terms

Active Duty (AD)—Applies to members serving full-time duty in the active military service of

the United States. It includes members of the RC serving on AD or full-time training duty, but

does not include full-time National Guard duty. The term Inactive Duty for Training does not apply

to this definition when considering healthcare eligibility.

AD Training or AD for Training—A tour of AD which is used for training members of the

Reserve components to provide trained units and qualified persons to fill the needs of the Armed

Forces in war or national emergency and such other times as the national security requires. The

member is under orders that provide for return to non-active status when the period of AD training

is completed. It includes annual training, special tours of AD for training, school tours, and the

initial duty for training performed by non-prior service enlistees.

Active Guard and Reserve—National Guard and Reserve members who are on voluntary active

duty providing full-time support to National Guard, Reserve, and Active Component organizations

for the purpose of organizing, administering, recruiting, instructing, or training the Reserve

Components. Also called AGR.

AHLTA—The Department of Defense legacy electronic health record, is a clinical information

system that generates, maintains, stores and provides secure electronic access to comprehensive

patient records.

Air Reserve Component (ARC)—Units, organizations, and members of the ANG and the AFR.

Attending Physician—The physician who has the primary responsibility for the medical

diagnosis and treatment of the patient.

Beneficiary—Persons entitled to benefits under the Uniformed Services Health Benefits Program

and this manual.

Business Associate—A person or entity that performs certain functions or activities that involve

the use or disclosure of protected health information on behalf of, or provides services to, a covered

entity defined in terms.

Child—The natural or adopted child of a sponsor, or in some cases for purposes of determining

eligibility for military health benefits, the unadopted step-child of a sponsor, or the legal ward of

a sponsor. To determine whether a minor child may consent to certain classes of healthcare, refer

to applicable state law, or for overseas locations local Medical Group (MDG) Operating

Instructions.

Chronic Medical Condition—A medical condition that active medical treatment cannot cure or

control. Chronic conditions may involve periodic acute episodes and may require intermittent

AFMAN41-210 10 SEPTEMBER 2019 207

inpatient care. Sometimes medical treatment may control a chronic medical condition sufficiently

to permit continuation of daily living activities such as work, or school.

Commander—The principle commissioned officer responsible for all activities, operations, and

resources under the officer’s control. Synonymous with commanding officer and commanding

officer in charge.

Comprehensive Medical Information—Patient’s name, rank, age, status (e.g., AD, RC) unit of

assignment or government occupational position, date of admission and/or date of treatment,

diagnosis, current medical status, whether the admission was routine or happened under emergent

circumstances, and the projected length of stay.

Convalescent Leave—An authorized leave status granted to AD uniformed service members

while under medical or dental care that is a part of the care and treatment prescribed for a member’s

recuperation or convalescence.

Continental United States (CONUS)—United States territory, including the adjacent territorial

waters, located within North America between Canada and Mexico (Alaska and Hawaii are not

part of CONUS).

Covered Entity—In the HIPAA rules as (1) health plans, (2) health care clearinghouses, and (3)

health care providers who electronically transmit any health information in connection with

transactions for which HHS has adopted standards. Generally, these transactions concern billing

and payment for services or insurance coverage.

Custodial Care—Healthcare for a patient who:

- Is mentally or physically disabled and expected to continue as such for prolonged period.

- Requires a protected, monitored, or controlled environment in an institution or home.

- Requires assistance to support the essentials of daily living.

- Is not under active and special medical, surgical, or psychiatric treatment that reduces the

disability to the extent necessary to enable the patient to function outside a protected, monitored,

or controlled environment.

Deceased Member—A person who was, at the time of death, a uniformed service AD member or

retired; or a retired member of a RC who elected to participate in the Survivor Benefit Plan (for

information on this plan, contact the Personal Affairs department at the local Military Personnel

Section), but died before reaching age 60.

Definitive Diagnosis—For purposes of an Medical Evaluation Board evaluation, any condition

that significantly interferes with performance of duties appropriate to a service member’s office,

grade, rank, or rating.

Dependency Determination—A determination by the Air Force Accounting and Finance Center,

that individuals may retain their status as dependents of an AD or retired member of the uniformed

services. A favorable dependency determination does not in itself establish an entitlement to

medical care. The dependency determination must also provide specifically for medical care.

Dependent—A term that has generally been replaced with “family member.” An immediate

family member of an AD or retired Uniformed Services member. See AFI 36-3002 for a detailed

explanation.

Direct Care System—The system of military hospitals and clinics around the world.

208 AFMAN41-210 10 SEPTEMBER 2019

Disability Evaluation System—A process maintained by the military Services to ensure a fit and

vital force by determining a service member’s fitness for continued military service. The Disability

Evaluation System should include a medical evaluation board, a physical evaluation board, an

appellate review process, and a final disposition.

Disposition—The removal of a patient from a MTF because of a return to duty or to home, transfer

to another MTF, death, or other termination of medical care. The term may also refer to change

from inpatient to outpatient status (for example, inpatient to subsisting elsewhere or convalescent

leave).

Emergency Care—The immediate medical or dental care necessary to save a person’s life, limb,

or sight, or to prevent undue suffering or loss of body tissue.

Extended AD—A tour of AD, normally for more than 90 days, that members of the RC perform.

Strength accountability changes from the RC to the AD force. AD for training is not creditable as

Extended AD.

Foreign Military Sales—That portion of United States security assistance authorized by the

Foreign Assistance Act of 1961, as amended, and the Arms Export Control Act of 1976, as

amended. This assistance differs from the Military Assistance Program and the International

Military Education and Training Program in that the recipient provides reimbursement for defense

articles and services transferred.

Former Spouse—As the status relates to this manual, an individual who is no longer married to

an AD member, but was in the past for a sufficient length of time to become eligible for healthcare.

Health Artifact and Image Management Solution (HAIMS)—Provides an enterprise-wide data

sharing and content management capabilities for all types of artifacts and images, including

radiographs, clinical photographs, electrocardiographs, waveforms, audio files, video files and

scanned documents.

Health Insurance and Portability Accountability Act (HIPAA) Breach—The acquisition,

access, use, or disclosure of protected health information (PHI) in a manner not permitted under

the HIPAA Privacy Rule which compromises the privacy or security of the PHI.

Highly Sensitive Records—Health records, correspondence (including working papers), and

laboratory results, which may have an adverse effect on the morale or character of the patient or

other person(s). Highly sensitive records include but are not limited to alleged or confirmed

information relating to the treatment of patients for sexual assault, criminal actions (including child

or spouse abuse), psychiatric or social conditions, or venereal disease. Claims against the

government (including malpractice) are also considered highly sensitive.

Inactive Duty Training—Authorized training performed by a member of a RC not on published

active orders and consisting of regularly scheduled unit training assemblies, additional training

assemblies, periods of appropriate duty of equivalent training, and any special additional duties

for RC personnel that an authority designated by the Secretary concerned, and performed by them

in connection with the prescribed activities of the organization in which they are assigned with or

without pay. Does not include work or study associated with correspondence courses.

Integrated Disability Evaluation System—The Integrated Disability Evaluation System

integrates the Disability Evaluation System with the Veterans Affairs (VA), and delivers the

AFMAN41-210 10 SEPTEMBER 2019 209

advantage of single-sourced disability ratings that are accepted by both the DoD and the VA, so

the member will receive a VA benefits decision shortly after separation or retirement.

International Military Education and Training—Formal or informal instruction provided to

foreign military students, and forces on a non-reimbursable (grant) basis by offices or employees

of the United States, contract technicians, and contractors. Instruction may include

correspondence courses; technical, educational or informational publications; and media of all

kinds.

Legally Aged Family Member—The age of 18 years and older, however, can vary by state law

with respect to the matter at issue.

Medical Care—Inpatient, outpatient, dental care, and related professional services.

MHS GENESIS—The new electronic health record for the

MHS, provides enhanced, secure technology to manage health information. MHS GENESIS

integrates inpatient and outpatient solutions that will connect medical and dental information

across the continuum of care, from point of injury to the military treatment facility.

Military Patient—A patient who is a member of the Uniformed Services of the United States on

AD, or RC status eligible for military care, or an AD member of a foreign government eligible for

military care.

Military Treatment Facility—A military treatment facility is every fixed facility established for

the purpose of furnishing medical and/or dental care to eligible individuals, including all

operations of each such facility and all health care delivery associated with each such facility.

Military Treatment Facility Commander or Director—The person appointed on orders as the

commanding officer of the MTF.

North Atlantic Treaty Organization—Security alliance of 28 countries with the fundamental

goal to safeguard the Allies’ freedom and security by political and military means. North Atlantic

Treaty Organization nations are: Albania, Belgium, Bulgaria, Canada, Croatia, Czech Republic,

Denmark, Estonia, France, Germany, Greece, Hungary, Iceland, Italy, Latvia, Lithuania,

Luxembourg, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain,

Turkey, the United Kingdom, and the United States.

Non-appropriated Fund Employee—A Government employee whose pay comes from other

than appropriated funds (for example, bowling alley and Base Exchange employees).

Power of Attorney—A legal document authorizing an individual to act as the attorney or agent

of the grantor. General rules and individual state laws specify when a power of attorney is

required. Refer any questions pertaining to powers of attorney to the legal office.

Prime Service Areas (PSAs)—Are areas in which the contractor offers enrollment in TRICARE

Prime in compliance with the travel time access standard. PSAs encompass the entire area of all

the ZIP codes lying within or intersected by the 40 mile radius around enrolling MTFs/enhanced

Multi-Service Markets (eMSMs) (both hospitals and clinics) and Base Realignment and Closure

(BRAC) sites. Zip codes enclosed entirely within a PSA’s boundary shall also be included. For

BRAC sites, the 40 mile radius shall be determined based on the physical address of the former

MTF location. If the former MTF address is no longer valid, the 40 mile radius shall be determined

from the geographic center of the BRAC site zip code as of the date of contract award.

210 AFMAN41-210 10 SEPTEMBER 2019

Reserve Components—Reserve components of the Armed Forces of the United States are: the

ANG of the United States, the AFR, the Army National Guard of the United States, the Army

Reserve, the Naval Reserve, the Marine Corps Reserve, and the Coast Guard Reserve. For the

purpose of this manual, the term also includes the reserve members of the commissioned corps of

the United States Public Health Service and National Oceanic and Atmospheric Administration.

Retiree—A former member of a uniformed service who is entitled to retired, retainer, or

equivalent pay, based on duty in a uniformed service.

Sanitized Healthcare Information—A patient’s name, rank, age, military status (AD, RC), unit

of assignment or government occupational position, date of admission and/or treatment date, and

whether the admission was routine or happened under emergent circumstances, as this information

applies to reporting an AD service member’s status to the authorized AD service member’s

commander or the commander’s properly appointed designee.

Sensitive Medical Information—Information that may affect the patient’s morale, character,

medical progress, or mental health. This includes the specific location or description of illness or

injury, which may prove embarrassing to the patient or reflect poor taste. If the patient consents,

information relating to the description of disease or injury and general factual circumstances may

be released. Note: To protect the sensitive nature of the information, records or documents will

be sent directly through medical channels when considered advisable by the healthcare provider

or MTF commander or director.

Transitional Assistance Management Program—Offers transitional healthcare coverage under

TRICARE Prime where offered, TRICARE Extra, and TRICARE Standard to certain separating

AD members and their eligible family members. Care is available for a limited time. Sponsors

may verify eligibility for themselves and their family members by visiting or contacting the nearest

uniformed services Identification card facility or contacting the Defense Manpower Data Center

Support Office toll free at (800) 538-9552. To locate the nearest Identification card facility, visit

www.dmdc.osd.mil/rsl/. Refer to paragraph 2.21 for additional information. Effective 1 January

2018, TRICARE Standard and Extra are replaced by TRICARE Select.

Treatment—A procedure or medical service that medical persons expect to lead to or assist in the

patient’s recovery.

TRICARE—The military’s managed healthcare program, overseen by the DoD in cooperation

with regional civilian contractors. TRICARE uses the MHS as the main delivery system

augmented by a civilian network of providers and facilities serving AD (including

Reservists/National Guard), their families and retired military/families and survivors world-wide.

TRICARE Prime Remote—TRICARE Prime Remote provides healthcare coverage through

civilian providers for those United States Uniformed Service Members and their families who are

on remote assignment. It applies to members of the Army, Navy, Marine Corps, Air Force, Coast

Guard, United States Public Health Service, and National Oceanic and Atmospheric

Administration. Eligible beneficiaries must live and work more than 50 miles or approximately

one hour's drive time from the nearest MTF. TRICARE Prime Remote is offered in the 50 United

States only.

Uniformed Services—The Army, Navy, Air Force, Marine Corps, Coast Guard, National Oceanic

and Atmospheric Administration, and United States Public Health Service.

AFMAN41-210 10 SEPTEMBER 2019 211

Uniformed Services Family Health Plan—US Family Health Plan is a TRICARE Prime option

There is a TRICARE Prime option available to eligible persons - including those who are age 65

and over - who live near selected civilian medical facilities around the country. These facilities

are called “designated providers” (DPs) - formerly known as Uniformed Services Treatment

Facilities.

United States—The 50 states and the District of Columbia, Puerto Rico, the US Virgin Islands,

and Guam.

Veteran—A person who served in the active military, Army, Navy, Coast Guard or Air Force. A

person who originally enlisted in a regular component of the Armed Forces after 7 September

1980, or who entered AD after 16 October 1981, is not eligible for benefits from the Department

of Veterans Affairs unless the member completes the lesser of 24 continuous months of AD or the

full period for which the person was called or ordered to duty. This provision does not apply to

veterans who have a compensable service-connected disability or who were discharged close to

the end of an enlistment term because of hardship, or a disability incurred or aggravated in line of

duty.

Wounded Warrior—Any service member who has sustained a combat or hostile-related injury

or illness requiring long-term care that will require a Medical Evaluation Board or Physical

Evaluation Board to determine fitness for duty.

Written Authorization—Written consent from the patient or authorized representative allowing

release or disclosure of information.

212 AFMAN41-210 10 SEPTEMBER 2019

Attachment 2

SECRETARY OF THE AIR FORCE DESIGNEE EXAMPLE REQUEST

Date

MEMORANDUM FOR (MAJOR COMMAND NAME AND ADDRESS)

FROM: (MILITARY TREATMENT FACILITY NAME AND ADDRESS)

SUBJECT: Secretary of the Air Force Designee Program Application

1. Request the following individual be granted Secretarial Designee status. The following

information is provided in accordance with AFMAN 41-210, Chapter 4.

a. The patient's full name.

b. The patient’s date of birth.

c. The patient’s relationship to sponsor.

d. Sponsor’s full name.

e. Sponsor’s rank.

f. Sponsor’s branch of service.

g. Last four numbers of the Sponsor’s social security number.

h. Sponsor’s military status (active duty retired, deceased) and reason for discharge or

separation.

i. The exact date Designee status should begin.

j. The recommended length of Designation.

k. Transportation aboard an aeromedical evacuation aircraft is/is not requested. Identify

whether the patient requesting Designee status might require transportation on aeromedical

evacuation. If so, include patient's home address and estimated cost of military transport.

l. Reason for Designation: for example, age (specify date of birth), marriage status, sponsor

leaving the service.

m. Justification: Identify both the primary program category/criteria best suited for the situation

and a supporting narrative.

n. Diagnosis: The application should include diagnosis in both clinical and layman's terms.

o. Brief Case History: The application needs a brief (one or two paragraph) case history. For

complex cases, attach a separate letter with additional details. Include a long-term prognosis, the

patient's age when medical providers first diagnosed the problem, and when and where DoD

sponsored care began. Histories must be understandable to non-medical personnel.

p. Name of attending physician.

q. Medical specialty required: Application should specify the type of medical specialist

(orthopedics, pediatrics, etc.) who would provide care for the patient.

r. Name, rank, and duty phone (Defense Switched Network and commercial) of the Secretarial

Designee caseworker.

s. Third Party Insurance Carrier: Identify if the sponsor, and or, applicant has Third Party

Insurance.

t. Third Party Insurance Carrier Policy Number.

u. Space Availability: Indicate if the military treatment facility (MTF) has the capacity to treat

the applicant.

AFMAN41-210 10 SEPTEMBER 2019 213

v. Like-care TRICARE Prime patients are/are not being deferred to the network. Indicate if

other TRICARE Prime beneficiaries with the same diagnosis are being deferred to the network.

w. Right of First Refusal status: Indicate if the MTF accepts/does not accept Right of First

Refusals.

2. For additional information please call the caseworker at the above phone number.

//SIGNATURE BLOCK//

214 AFMAN41-210 10 SEPTEMBER 2019

Attachment 3

CONSULT NOTES AND SPECIALTY STUDIES GUIDE

Table A3.1. Consult Notes and Specialty Studies Guide.

Diagnosis

Required Consults

Required Studies/Info

Asthma

Pulmonology (ONLY if

Complicated)

Spirometry (MCT or HC if diagnosis in

doubt)

Burns

% BSA, ROM, Photographs of

affected areas

Collagen Vascular Disease

Rheumatology

Arthritis

Rheumatology

Fibromyalgia

Rheumatology

Trigger point summary

Coronary Artery Disease

Cardiology

ETT, Echo or Cath, NYHA class

Diabetes

Endocrinology if Insulin

Dependent

FBS, A1C, Optometry or

Ophthalmology

Hearing

ENT

Audiogram

Eyes

Ophthalmology

Visual Acuity and Visual Field exam

Neuromuscular

Orthopedics (PT if available)

ROM (percent), Strength, Function,

EMG if appropriate

Musculoskeletal

Orthopedics (PT if available)

ROM (percent), Strength, Function

Cancer (Brain)

Oncology, neurosurgery, & psych

5 year prognosis

Cancer (Skin)

Dermatology

5 year prognosis

Cancer (Head and Neck)

ENT

5 year prognosis

Cancer (renal or GU)

Urology

5 year prognosis

Cancer (other)

Oncology

5 year prognosis

Multiple Sclerosis

Neurology

MRI, spinal tap

Headache

Neurology

MRI, Log with # prostrating HA’s last

12 months

Seizure

Neurology

EEG, MRI, Log of seizure frequency

Renal

Neurology

Lab progression over time

Crohn’s/Ulcerative Colitis

Scope/Biopsy, Log of flare freq &

severity

Psych

MD/DO Psych review and cosign

Military & Social-Industrial

Impairment

TBI

Neuropsychiatry

MRI, Military & Social-Industrial

AFMAN41-210 10 SEPTEMBER 2019 215

Impairment

216 AFMAN41-210 10 SEPTEMBER 2019

Attachment 4

INITIAL RILO COVER SHEET/ CHECKLIST

Figure A4.1. Initial RILO Cover Sheet/Checklist.

AFMAN41-210 10 SEPTEMBER 2019 217

218 AFMAN41-210 10 SEPTEMBER 2019

Attachment 5

PERSONNEL RELIABILITY ASSURANCE PROGRAM ADMIN CERT HAIMS SCAN

GUIDE

Figure A5.1. Personnel Reliability Assurance Program Admin Cert HAIMS Scan Guide.

AFMAN41-210 10 SEPTEMBER 2019 219

220 AFMAN41-210 10 SEPTEMBER 2019

Attachment 6

ARRANGEMENT OF FORMS IN THE AF FORM 2100A SERIES, HEALTH RECORD

OUTPATIENT SECTION 1

Table A6.1. Arrangement of Forms in the AF Form 2100A Series, Health Record

Outpatient Section 1.

Form Number and Title

Special Instructions

DD Form 2766, Adult Preventive and Chronic

Care Flowsheet , and/or, AF Form 1480a, Adult

Preventive and Chronic Care Flowsheet

Note: AF Form 1480A, and the AF Form

4320 have been replaced by DD forms,

same title. Whichever form is used, (DD

Form 2766, AF Form 1480, or AF Form

4320), this form is always the top form

filed in section I. Transcribe pertinent

information from older forms to each

subsequent new form(s) and file the old

form(s) underneath the newer form in

section I. DO NOT remove/discard the

old forms. File old forms underneath the

current version.

DD Form 2882, Pediatric & Adolescent

Preventive and Chronic Care Flowsheet, and/or,

AF Form 4320, Pediatric & Adolescent

Preventive and Chronic Care Flowsheet

DD Form 2766C or AF Form 1480B, Adult

Preventive and Chronic Care Flowsheet –

Continuation Sheet

File after/behind the DD Form 2766, AF

Form 1480A, or AF Form 4320. This

form is used as a continuation form for

documenting information that cannot fit on

DD Form 2766 or AF Form 1480A, or for

local requirements. The Aerospace

Services Information Management System

(ASIMS) also utilizes an automated

version of the form. Each time a member

receives an updated immunization, ASIMS

may generate an updated paper form. If an

updated form is generated, discard the

previous form ONLY after ensuring the

latest form contains BOTH historical and

current immunization data, then file the

new form in its place.

DD Form 2795, Pre-Deployment Health

Assessment Questionnaire

File the DD Form 2796, DD Form 2844,

and DD Form 2900 (post deployment

assessment forms) after the corresponding

DD Form 2795 that each form is

associated with.

DD Form 2796, Post-Deployment Health

Assessment

DD Form 2844, Medical Assessment Post-

Deployment

DD Form 2900, Post-Deployment Health RE-

Assessment

Form Number and Title

Special Instructions

AFMAN41-210 10 SEPTEMBER 2019 221

AF Form 1480, Summary of Care

Information will be transcribed from the

AF Form 1480 onto the DD Form 2766 or

AF Form 1480A. Do not discard old

forms. File under the oldest DD Form

2766.

AF Form 3922, Adult Preventive Care –

Flowsheet

Transcribe the AF Form 3922 information

in the same way as the AF Form 1480 and

file it after the AF Form 1480.

AF Form 3923, Child Preventive Care –

Flowsheet

Transcribe the AF Form 3923 information

onto the AF Form 4320.

DD Form 2569, Third Party Collection Program

(TPCP) – Record of Other Health Insurance

1. File here unless military treatment

facility (MTF) policy is to maintain the

form in the resource management

(business) office or in an authorized

electronic format and stored in an

enterprise-wide electronic clinical

documentation database. File the most

current form. Remove older, outdated

forms. This form must be updated

annually or upon change of patient

information. The form must be validated

at every encounter as being current and

correct. This form contains Personally

Identifiable Information and must be

safeguarded if maintained apart from the

outpatient medical record.

2. Filing Options:

a. Continue with current process of

maintaining a hardcopy of this form filed

in the outpatient medical record.

b. Capture and store the form

electronically. The stored e-file must be

saved with the following naming

convention: Last Name (or first 8

characters), First Initial, family member

prefix, Last 4 of Sponsor’s social security

number, Month/Year of patient or adult

family member signature with dashes

separating each data entry, e.g., (Jones, D-

20-4567-0910). Stored electronic forms

will not be available to anyone without

authorized, need to know, TPCP or clinic

staff member access. MTF Data Quality

auditors and TPCP contract support

personnel must have access to the

Form Number and Title

Special Instructions

222 AFMAN41-210 10 SEPTEMBER 2019

electronic forms database. Obsolete or

outdated electronic forms may be

deleted/destroyed in accordance with

applicable records management rules.

c. Maintain the original hardcopy form in

the MTF RMO, business office, or TPCP

office. The form should be filed by

signature date/month and alphabetically

thereafter. During non-business hours,

store in a secure location, which offers at

least one locked door between the filed

documents and the outside hallway or

office entrance. Destroy form/file one year

after date of signature of the form, or when

replaced by an updated signed form.

d. File this form for non-enrolled/non-

empaneled patients who otherwise do not

receive regular direct care from the MTF

and/or there is no paper medical record

already on file, in either the MTF

outpatient records department or in the

RMO/business office, TPCP office. File

forms by signature date/month and

alphabetically thereafter. During non-

business hours, store in a secure location,

which offers at least one locked door

between the filed documents and the

outside hallway or office entrance.

Destroy form/file one year after date of

signature of the form, or when replaced by

an updated signed form.

3. Each MTF will choose one option for

filing the form. If not already

accomplished, the MTF must communicate

the option of choice to their TPCP contract

partner. Regardless of the filing option

choice, the TPCP contractor must receive

the original or copy of all DD Forms 2569

before final filing.

AF Form 565, Record of Inpatient Treatment

(or approved Composite Health Care System

(CHCS) computer generated form)

Copy of original, or similar document used

by the United States Army, United States

Navy, or Department of Veterans Affairs

medical facilities.

Form Number and Title

Special Instructions

AFMAN41-210 10 SEPTEMBER 2019 223

AF Form 560, Authorization and Treatment

Statement

Original – Only necessary if admission

was cancelled. Previously filed AF Forms

560 will not be removed.

SF 502, Medical Record - Narrative Summary

Copy of original.

SF 509, Medical Record – Progress Notes

File a copy of original, when used as a

final discharge note or discharge

instruction.

SF 515, Medical Record – Tissue Examination

File a copy of original report if the

procedure relates to inpatient care; file the

original report if the procedure relates to

outpatient care if not already filed in an

EAR.

SF 516, Medical Record – Operation Report

File a copy of original report if the

procedure relates to inpatient care; file the

original report if the procedure relates to

outpatient care if not already filed in the

EAR.

OF 517, Clinical Record – Anesthesia

File a copy of the original document if

episode of care relates to inpatient report

(if there was an anesthetic incident); file

the original document if the care relates to

an outpatient episode.

OF 522, Medical Record – Request for

Administration of Anesthesia and for

Performance of Operations and Other

Procedures

Copy of all documentation relating to

ambulatory surgery.

224 AFMAN41-210 10 SEPTEMBER 2019

Attachment 7

ARRANGEMENT OF FORMS IN THE AF FORM 2100A SERIES, HEALTH RECORD

OUTPATIENT SECTION 2

Table A7.1. Arrangement of Forms in the AF Form 2100A Series, Health Record

Outpatient Section 2.

Form Number and Title

Special Instructions

AF Form 745, Sensitive Duties Program Record

Identifier

Always the top form in this section when

used.

AF Form 966, Registry Record

Filed after AF Form 745, if used.

SF 600, Health Record – Chronological Record

of Medical Care

SF 600s from single-visit encounters (e.g.

Health Assessment Overprints), with no

other associated supporting paperwork,

should be filed in chronological order,

most current form filed on top of the other

single-visit SF 600s.

OF 558, Medical Record – Emergency Care and

Treatment

Interfile OF 588 with applicable SF 600s

in date order. Forward original to the

inpatient unit and file with the inpatient

record if the patient is admitted.

DD Form 2161, Referral for Civilian Medical

Care

File these forms on top of the SF 600 to

which it belongs.

SF 513, Consultation Report

AF Form 1535, Physical Therapy Consult

AF Form 1352, Hyperbaric Patient Information

and Therapy Record

Original if treatment was on an outpatient

basis. File the most recent form on top of

all others.

AF Form 1446, Medical Examination – Flying

Personnel

Signed original.

DD Form 2697, Report of Medical Assessment

OF 178, Certificate of Medical Examination

Applies to civilian employees only.

SF 88, Report of Medical Examination or DD

Form 2808, Report of Medical Examination

Signed copy of each report. When DD

Form 2161 or any other form is prepared

in conjunction with the SF 88/DD Form

2808, it is filed with the SF 88/DD Form

2808.

SF 93, Report of Medical History, DD Form

2807-1, Report of Medical History or DD Form

2807-2, Medical Prescreen of Report of Medical

History

Signed copy of each report. File civilian

employee’s SF 93/DD Form 2807-1/DD

Form 2807-2 in the health record.

Note:

Ensure inter-related documents for the same episode of care or subsequent referral care

documents are filed on top of the initial encounter document.

AFMAN41-210 10 SEPTEMBER 2019 225

Attachment 8

ARRANGEMENT OF FORMS IN THE AF FORM 2100A SERIES, HEALTH RECORD

OUTPATIENT SECTION 3

Table A8.1. Arrangement of Forms in the AF Form 2100A Series, Health Record

Outpatient Section 3.

Form Number and Title

Special Instructions

AF Form 348, Line of Duty Determination

AF Form 422, Physical Profile Serial Report

Filed chronologically with most recent

report on top.

AF Form 469, Duty Limiting Condition Report

Most recent

Prenatal Forms

Prenatal forms will be maintained in the

OB-GYN clinic until the mother delivers.

If the mother delivers in a civilian facility

the forms will be filed in the outpatient

record.

SF 533, Medical Record – Prenatal and

Pregnancy

If the mother did not deliver in the

hospital, the prenatal record is filed as a

whole package with all forms pertaining to

prenatal treatment filed chronologically

between the SF 533 and AF Form 3915.

AF Form 618, Medical Board Report

Signed copy of original and associated

documents.

DD Form 2992, Medical Recommendation for

Flying or Special Operational Duty

File a copy of the most current

recommendation for or against (either

temporary or permanent suspension) flying

status or special operational duty. File the

AF Form 1418 with the DD Form 2992,

the SF 88, or any other form prepared in

conjunction with DD Form 2992. Keep all

supporting documents even though the DD

Form 2992 may be destroyed. Remove the

DD Form 2992, specifically prepared for

annual or incoming clearance, from the

record and destroy when it expires.

Remove and destroy any DD Form 2992

excusing, grounding, or disqualifying an

individual for flying or special operational

duty after the new DD Form 2992

returning the individual to medically

approved/cleared status is filed.

AF Form 1418, Recommendation for Flying

or Special Operational Duty – Dental

Form Number and Title

Special Instructions

226 AFMAN41-210 10 SEPTEMBER 2019

AF Form 137, Footprint Record

AF Form 137 is filed on top of DD Form

2005. Note: The September 1988 edition

of AF Form 2100A series has the Privacy

Act Statement printed on the folder. It is

not required to place DD Form 2005 in

these folders.

All other forms not listed in Section 1, 2, and 4

File all other forms in chronological order

by date, including letters and copies of

reports of care from civilian sources

(reviewed by the military healthcare

provider) and locally generated forms.

DD Form 2005

For records that do not have a Privacy Act

statement preprinted on the record folder.

Disclosure Accounting Record

The purpose of the document is to

maintain a record of patient information

released. This document will contain the

following information: individual’s name

(e.g., patient); requestor’s name and

address; nature of disclosure; individual’s

consent with a block for annotating “Yes”

or “No, not required;” and date of

disclosure.

Disclosure Accounting Record (continued)

Until such time as this form is printed on

the AF Form 2100A series folder, each

MTF will develop a local form containing

space for the requested information with

space for entry of multiple requests.

AFMAN41-210 10 SEPTEMBER 2019 227

Attachment 9

ARRANGEMENT OF FORMS IN THE AF FORM 2100A SERIES, HEALTH RECORD

OUTPATIENT SECTION 4

Table A9.1. Arrangement of Forms in the AF Form 2100A Series, Health Record

Outpatient Section 4.

Form Number and Title

Special Instructions

Laboratory Forms

File in chronological order with most

current laboratory results/report filed on

top.

SF 601, Health Record – Immunization Record

Used by United States Army, United

States Navy, Air National Guard (ANG),

and United States Air Force Reserve

(AFR).

SF 602, Health Record – Serology Record

SF 519B, Medical Record – Radiological

Consultation Request Report

Filed in chronological order by date with

the most recent on top.

OF 520, Medical Record-Electrocardiographic

Record, (or automated EKG report)

Filed together in chronological order by

date (the most recent on top), except when

OFs 520 attached as documentation to

reports, are filed with other reports. Filing

a copy of the inpatient electrocardiograms

(EKGs) in the outpatient record is

optional. Facilities with computer

generated EKG reports may destroy OF

520 after the test has been ordered and if

all patient identification is on the

automated report.

AF Form 1721, Spectacle Prescription

DD Form 2215, Reference Audiogram

DD Form 2216, Hearing Conservation Data

AF Form 1671, Detailed Hearing Conservation

Data Follow-up

AF Form 190, Occupational Illness/Injury

Report

AF Form 1527, History of Occupational

Exposure to Ionizing Radiation

USAFSAM Form 1527-1, Annual Report of

Individual Exposure to Ionizing Radiation

USAFSAM Form 1527-2, Cumulative

Occupational Exposure History to Ionizing

Radiation

AF From 1753, Hearing Conservation

Examination

228 AFMAN41-210 10 SEPTEMBER 2019

AF Form 2755, Master Workplace Exposure

Data Summary

Form Number and Title

Special Instructions

AF Form 2769, Supplemental Data Sheet

AF Form 895, Annual Medical Certificate

OTHER DIAGNOSTIC TEST RESULTS and/or

flat disc digital MEDIA not already stored in the

patient’s electronic health record or specifically

mentioned in this attachment.

Note: Some MTFs may receive referral

results from civilian providers in the form

of CD-ROM digital media. If no

capability exists to transfer/convert this

information into Armed Forces Health

Longitudinal Technology Application

(AHLTA), print the information from the

CD-ROM and file in the appropriate

outpatient records department.

Advance Directives (Self Determination Act

forms), durable Power of Attorney forms, organ

donor forms

AFMAN41-210 10 SEPTEMBER 2019 229

Attachment 10

ARRANGEMENT OF FORMS IN THE INPATIENT RECORD

Table A10.1. Arrangement of Forms in the Inpatient Record.

Form Number and Title

Special Instructions

AF Form 565, Record of Inpatient Treatment

Original, typed, or electronic. Filed on top

of all other applicable forms. File all other

forms (listed below) for the same episode

of care beneath this form in listed order.

AF Form 560, Authorization and Treatment

Statement

Original with physician’s signature, or

initials, and signature stamp at bottom.

*AF Form 618, Medical Board Report

With attachments as a complete package

when prepared.

SF 502, Medical Record-Narrative Summary

(Clinical Resume)

Unless included in Medical Board package.

SF 503, Medical Record-Autopsy Protocol

DD Form 1322, Aircraft Accident Autopsy

Report

When used instead of SF 503 for reporting

autopsies performed on aircraft accident

fatalities.

SF 504, Clinical Record-History Parts I and II

SF 505, Clinical Record-History Parts II&III

SF 506, Clinical Record-Physical Examination

SF 539 (or DD Form 2770), Medical Record-

Abbreviated Medical Record

When used instead of, or in addition to SF

504-506.

SF 558, Medical Record-Emergency Care and

Treatment

When patient is admitted through the ER;

Original.

*SF 507, Clinical Record Report On ____ or

Continuation of SF Report_______

Always file as an attachment to the form to

which it pertains. Do not separate from

that form.

*OF 275, Medical Record Report

When used in lieu of a SF, AF or DD form,

file in place of that form.

SF 535, Clinical Record-Newborn

SF 509, Medical Record-Progress Notes

When appropriate place preadmission SF

600s in front of SF 509

SF 513, Consultation Report

DD Form 2161, Referral for Civilian Medical

Care

SF 515, Medical Record-Tissues Examination

If an AFIP report is prepared, file it beneath

the SF 515 to which it pertains

SF 516, Clinical Record-Operation Report

OF 517, Medical Record-Anesthesia Recovery

Room Record

AF Form 1864, Preoperative Nursing Record

Form Number and Title

Special Instructions

230 AFMAN41-210 10 SEPTEMBER 2019

OF 522, Medical Record-Request for

Administration of Anesthesia and for

Performance of Operations and Other

Procedures

Or locally approved form (check with State

Requirements).

SF 533, Medical Record – Prenatal and

Pregnancy

Prenatal record is filed as a whole package

with all forms pertaining to prenatal

treatment filed chronologically between the

SF 533 and AF Form 3915.

AF Form 3915, Labor and Delivery Flow Sheet

Prenatal record is filed as a whole package

with all forms pertaining to prenatal

treatment filed chronologically between the

SF 533 and AF Form 3915.

AF Form 1302, Request and Consent for

Sterilization

AF Form 1225, Informed Consent for Blood

Transfusion

SF 523, Medical Record-Authorization for

Autopsy

OF 523B, Medical Record-Authorization for

Tissue Donation

SF 518, Medical Record-Blood or Blood

Component

SF 519B, Medical Record – Radiological

Consultation Request Report

OF 520, Medical Record-Electrocardiographic

Record or automated electrocardiograph (EKG)

report

Facilities with computer generated EKG

reports may destroy the OF 520 after the

test is ordered and all patient identification

is on the automated report.

SF 546, Chemistry I

SF 541, Medical Record-Gynecologic Cytology

SF 547, Chemistry II

SF 548, Chemistry III (urine)

SF 549, Hematology

Facilities having Coulter Counter Model S,

Use AF Form 1976-Hematology instead of

SF 549.

SF 550, Urinalysis

SF 551, Serology

SF 552, Parasitology

SF 553, Microbiology I

SF 554, Microbiology II

SF 555, Spinal Fluid

SF 557, Miscellaneous (Note: Laboratory

Reports may be computerized)

Form Number and Title

Special Instructions

DD Form 741, Eye Consultation

AFMAN41-210 10 SEPTEMBER 2019 231

AF Form 1412, Occupational Therapy

Treatment Record

AF Form 1535, Physical Therapy Consultation

AF Form 1536, Physical Therapy Consultation

Continuation Sheet Record

SF 521, Medical Record-Dental

SF 524, Medical Record-Radiation Therapy

SF 525, Medical Record-Radiation Therapy

Summary

SF 526, Medical Record-

Interstitial/Intercavitary Therapy

SF 527, Medical Record-Group Muscle

Strength, Joint R.O.M., Girth and Length

Measurements

SF 528, Medical Record-Muscle Function by

Nerve Distribution: Face, Neck and Upper

Extremity

SF 529, Medical Record-Muscle Function by

Nerve Distribution: Trunk and Lower Extremity

SF 530, Medical Record-Neurological

Examination

SF 531, Medical Record-Anatomical Figure

AF Form 3066 (or 3066-1), Doctor’s Orders

AF Form 3069, Medication Administration

Record

AF 3068, PRN Medication Administration

Record

AF 3067, Intravenous Record

AF Form 3241, Adult Admission Note

AF Form 3242, Adult Patient Care Plan

AF Form 3244, Pediatric Admission Note

AF Form 3245, Pediatric Patient Care Plan

AF Form 3247, Neonatal Admission Note

AF Form 3248, Neonatal Patient Care Plan

AF Form 3250, Obstetric Patient Care Plan

AF Form 3252A, Mental Health Patient Care

Plan

AF Form 3254, Patient Care Plan

AF Form 3256, Patient/Family Teaching Flow

Sheet

SF 511, Medical Record-Vital Signs Record

SF 512, Medical Record-Plotting Chart

Form Number and Title

Special Instructions

SF 512A, Medical Record-Plotting Chart-Blood

Pressures

232 AFMAN41-210 10 SEPTEMBER 2019

DD Form 792, Twenty-Four Hour Patient Intake

and Output Worksheet (if local requirements to

file)

Other prescribed nursing forms

AF Form 570, Notification of Patient’s Medical

Status

AF Form 1122, Personal Property Inventory

AF Form 1122A, Personal Property Inventory

(Continuation Sheet)

Birth Certificate and Worksheet

Death Certificate

AF Form 438, Medical Care - Third Party

Liability Notification

DD Form 2569, Third Party Collection Program

– Other Health Information

File the most up-to-date form signed by the

patient or legally authorized representative.

Admitted patients or legally authorized

representative will sign this form prior to or

at the time of admission.

Other command and local administrative forms

Other release of information forms

Correspondence Records received with

transferred patients

*DD Form 602, Patient Evacuation Tag

File beneath the SF 502 from the

transferring MTF.

AFMAN41-210 10 SEPTEMBER 2019 233

Attachment 11

SERVICE TREATMENT RECORDS MAILING ADDRESSES FOR OTHER SERVICES

U.S. Army:

AMEDD Record Processing Center

3370 Nacogdoches Road, Suite 116

San Antonio, TX 78217

U.S. Navy:

Navy Medicine Records Activity (NMRA)

BUMED Detachment St. Louis

4300 Goodfellow Blvd, Bldg. 103

St. Louis, MO 63120

U.S. Marine Corps:

Marine STR Processing Center (MRA)

Attn: STRRCC

3280 Russell Road

Quantico, VA 22134

U.S. Coast Guard:

Commanding Officer

USCG Health, Safety, and Work-Life Service Center (MA)

300 E. Main Street, Suite 1000

Norfolk, VA 23510-9109

USPHS – U.S. Public Health Service

Office of Commissioned Corps Support Services

Medical Affairs Branch

5600 Fishers Lane, Parklawn Building, Room 4C-04

Rockville, MD 20857-0001

NOAA – National Oceanic and Atmospheric Administration

U.S. Public Health Service

Commissioned Personnel Center

Attn: CDR Hobson-Powell

National Oceanic and Atmospheric Administration

8403 Colesville Road, Suite 500

Silver Spring, MD 20910

See AFMOA Kx/Health Benefits/STR/STR Guidance for address updates at:

https://kx.health.mil/kj/kx2/AFMOAHealthBenefits/Pages/home.aspx.