Download the form
DA Form 5009 is a DA series document issued for use across the Department of the Army. Official title: MEDICAL RECORD - RELEASE AGAINST MEDICAL ADVICE. Purpose: medical record - release against medical advice. The current edition carries the date 02/01/2004 and is listed with a publication status of ACTIVE. The form runs to 1 page(s) and contains approximately 125 entry fields.
Responsibility for content and revision lies with TSG. The prescribing directive is AR 40-68, 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.
Distributed formats: PDF, XFDL. The layout is common to all of them; what varies is the method of entry. The pdf is the reference version. In the fillable pdf the entry areas are live objects that accept typing; in the printable version the same areas are inert and are filled by hand after printing.
The pdf displays in current browsers and in any reader application. For fillable use a full reader is preferable to a browser viewer, since viewers vary in whether entered data is retained. An xfdl file is available too. The format is IBM Lotus Forms, in use across Army form systems, and it opens only in the Lotus Forms Viewer.
Download of every format is free and requires no account. Files are served as published, without alteration to the page image.
What the form asks for
- ContentArea1
- DATE
- Dept
- FIELD1
- FIELD10
- FIELD11
- FIELD12
- FIELD13
- FIELD14
- FIELD15
- FIELD16
- FIELD17
- FIELD18
- FIELD19
- FIELD2
- FIELD21
- FIELD22
- FIELD24
- FIELD3
- FIELD4
- FIELD5
- FIELD6
- FIELD7
- FIELD8
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.
Companion forms are traced by series and number. Within the DA series, documents sharing a proponent or a governing directive are frequently required together, and a form cited on the face of another is generally submitted alongside it. Continuation sheets, covers, and transmittal forms are part of that set and are assembled in advance of submission.
An edition stands until the proponent issues a revision. The printed edition date identifies the version, and a copy held locally is checked against the edition now in force before reuse. Prior executions under a superseded edition are not reopened for that reason.
The files here are reproductions of published Department of the Army documents, provided for download. This site is not part of the Department of the Army and issues no forms of its own. Nothing on this page is legal advice, and no representation is made as to acceptance of a document by any office. Where an entry, a requirement, or a question of eligibility is in doubt, the proponent or the servicing administrative office answers it.
Questions and answers
- What is DA Form 5009?
- MEDICAL RECORD - RELEASE AGAINST MEDICAL ADVICE
- Which edition is current?
- 02/01/2004
- Who is responsible for this form?
- TSG
- In which formats can it be downloaded?
- PDF, XFDL, PDF
Publisher notes
- 14-REQUIRES PRIVACY ACT STATEMENT (AR 340-21)
- 42-ITEM ONLY PRODUCED IN ELECTRONIC MEDIA