Security Levels

Medically Related Forms

All forms can be found on the CG-611 web site http://www.uscg.mil/forms/. Below are common forms used by medical. If you would like a form added to the list below contact the appropriate program manager.

Medically related Forms
Form Number	Form Title
CG-4920	EVALUEE'S STATEMENT REGARDING THE FINDINGS OF THE MEDICAL BOARD REPORT
CG-5214	EMERGENCY MEDICAL TREATMENT REPORT
CG-5447	HISTORY AND REPORT OF OMSEP EXAMINATION
CG-5447A	PERIODIC HISTORY AND REPORT OF OMSEP EXAMINATION
CG-5684	MEDICAL BOARD COVER SHEET
CG-6020	MEDICAL RECOMMENDATION FOR FLYING DUTY
CG-6049	PERSONAL FITNESS PLAN
DD-771	EYEWEAR PRESCRIPTION
DD-877	Request for Medical / Dental Records
DD-2215	REFERENCE AUDIOGRAM
DD-2216	HEARING CONSERVATION DATA
DD-2569	THIRD PARTY COLLECTION PROGRAM/MEDICAL SERVICES ACCOUNT/ OTHER HEALTH INSURANCE
DD-2642	TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT
DD-2807-1	REPORT OF MEDICAL HISTORY
DD-2808	REPORT OF MEDICAL EXAMINATION
DD-2813	DEPARTMENT OF DEFENSE ACTIVE DUTY/RESERVE FORCES DENTAL EXAMINATION
DD-2870	AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION
DD-2871	REQUEST TO RESTRICT MEDICAL OR DENTAL INFORMATION
SF-513	CONSULTATION SHEET
SF-558	EMERGENCY CARE AND TREATMENT
SF-600	CHRONOLOGICAL RECORD OF CARE
SF-603	DENTAL CHART
SF-603a (modified)	DENTAL CONTINUATION (MODIFIED)

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Last Modified 4/22/2010