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DA Form 4254 is a Department of the Army form in the DA series. Title of record: REQUEST FOR PRIVATE MEDICAL INFORMATION. Function: request for private medical information. The edition presently published bears the date 02/01/2003, with a status of ACTIVE. Physical extent is unknown page(s) and about unknown fillable fields.
Responsibility for content and revision lies with TSG. The prescribing directive is AR 40-66, which sets both the trigger for use and the disposition of the completed document. Entry is made by the named party or by the records clerk holding the file, with review and signature applied in the prescribed order.
Available formats: PDF. Each is a rendering of the same official layout; the content is identical across them and only the means of completion differs. The pdf is the reference copy. Fillable pdf carries interactive form fields; a printable pdf is the same page image without them, intended for pen entry after printing.
Any modern browser or reader will display a pdf. Interactive fields behave more predictably in a standalone reader than in an in-browser viewer, which sometimes shows fields it cannot store.
Every format is available at no charge and without sign-up. Files are distributed exactly as published, with no changes to the page.
The blocks are worked through in the order they appear on the sheet. At the head sit the identifying entries: name, identification number, unit, date. Because the filed record is indexed on these, they precede everything substantive.
Typed entry is made straight into the interactive fields. The tab key moves through them in the order set at build time, generally matching the reading order of the page. Boxes and buttons respond to a click; in an exclusive group, one selection cancels the others. Single-line fields do not wrap, and anything longer than the field width prints cut off although it may still display in full on screen. Extended text goes to remarks or a continuation sheet rather than into a narrow box.
The signature block is the final entry, made by hand or by an authorised electronic method, and without it the document remains a draft. Countersignatures — review, approval, witness — are added in the sequence printed, dated at the moment of signing and not at preparation. Empty mandatory fields lead the list of defects; an inapplicable field is annotated as such, not passed over. Behind it come digit transposition in identification numbers, day-month inversion in dates, and residual entries surviving from a reused copy in place of a blank form.
Where personal information is gathered, the form carries a Privacy Act statement giving the collection authority, the purpose, the routine uses, and the mandatory or voluntary character of the disclosure. It is read before entries are made rather than afterwards. A completed copy holds personal data and is stored and transmitted under the corresponding safeguards.
Once completed, the form goes where the governing authority directs: to the designated office, along the unit administrative channel, or into the personal file. The preparer retains a copy. The length of retention and the manner of filing are set by the records schedule for the series, not by local arrangement.
Related forms are found by series and number. Documents in the DA series sharing a proponent or a prescribing directive commonly travel together, and a form referenced within the body of another is usually filed with it. Continuation sheets, cover sheets, and transmittal documents belong to this group and are collected before submission rather than after.
Revision by the proponent supersedes an edition. Version is read from the edition date printed on the form itself, and a stored copy is compared against the current edition before it is used again. Documents already executed under an earlier edition are not redone because of the change.
What is offered here are copies of published Department of the Army documents, made available for download. The site is independent of the Department of the Army and publishes no forms of its own. The material is informational and not legal advice, and no statement is made about whether any office will accept a given document. Questions of entry, requirement, or eligibility go to the proponent or the servicing administrative office.
Questions and answers
- What is DA Form 4254?
- REQUEST FOR PRIVATE MEDICAL INFORMATION
- Which edition is current?
- 02/01/2003
- Who is responsible for this form?
- TSG
- In which formats can it be downloaded?
Publisher notes
- 42-ITEM ONLY PRODUCED IN ELECTRONIC MEDIA