Patient Administration Division
Office of the Chief
Format to Be Used for Preparing a Medical Statement
1. The physician will prepare a medical statement:
a. Use letterhead stationery for the medical statement with the signature block/signature of the physician preparing the medical statement. Some departments require review and co-signature by the department chief before the statement may be released to the patient. When the medical statement is complete and signed, deliver it to the PAD Correspondence Section, Room G1A152 (Oceanside basement), the Release of Information Office for the MEDCEN.
b. Identify the patient by full name, DOB, and relationship to the sponsor., sponsor’s name, rank, and SSN, patient’s address and telephone number, diagnosis, date of diagnosis, and, for Secretary of the Army Designee requests, the prognosis with projected period of time medical care will be required, all in bullet format.
c. Provide medical background information identifying the problem, condition, or reasons leading to the request.
d. Summarize the overall purpose, goal, or benefit to be achieved in approving this request.
e. Name, rank, medical department/service and the telephone number of the physician who most recently treated the condition/is preparing the medical statement.
f. Documentation from the MTF verifying that the requested care is available.
g Any other information or documentation that the requester believes will strengthen the chances for approval. If the medical statement is for Secretary of the Army Designee Status, stress the need for continuity of care, benefit to TAMC’s training program, etc.
2. Patient Administration Division will prepare for the Commander’s signature a memorandum forwarding the request through MEDCOM to the Office of the Secretary of the Army for consideration and response. This memorandum will contain administrative information, including:
a. The sponsor’s service affiliation, address, and telephone number, and whether separating from military service was on a voluntary or involuntary basis (if applicable).
b. Verification through DEERS of the expiration date for eligibility for care. Length of time for which designee status is requested.
c. Whether or not access to the aeromedical evacuation system is necessary.
d. Attempts made to obtain care from state and local agencies
e. Documentation attached that the applicant has been advised of care available under the Continued Health Care Benefits Program (information available from the Health Benefits Advisors, Managed Care Division, with offices inside the TRIWEST Office on the 1st floor of TAMC).