Attachment 0002 - C-5 DA Form 5018-R.pdf
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- Solicitation number
- W9124J26RRESP
About this file
This is a DA Form 5018-R, a client consent statement template used by the Army Alcohol and Drug Abuse Prevention and Control Program (ADAPCP) for the authorized release of treatment information.
The form enables clients to voluntarily consent to the disclosure of their personal medical records—including identity, diagnosis, prognosis, and treatment information—maintained by Army installations in connection with alcohol or drug abuse education, training, treatment, rehabilitation, or research. The consent applies to records held by the specified MEDCEN/MEDDAC (Medical Center/Medical Department Activity) and authorizes release to designated recipients for stated purposes, such as background check requirements per Department of Defense Instruction 1402.05 and Army Directive 2014-23. Section B establishes expiration and revocation provisions: clients may revoke consent at any time unless the disclosure has already been executed, or alternatively, consent automatically expires 60 days from the date signed or upon change in criminal justice status. However, clients whose release from confinement, probation, or parole is conditioned on ADAPCP participation cannot revoke consent until formal termination of that conditional release. Section C requires approval from the MEDCEN/MEDDAC Commander, Program Physician, or Clinical Director, who must certify that releasing the client's program status evaluation will not cause harm. The form requires signatures from the client, a witness, and the approving authority, along with corresponding dates.
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Text version
SIGNATURE OF CLIENT DATE
NAME OF WITNESS (Type or print) SIGNATURE DATE
NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE (Type or print) DATE
SIGNATURE
ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION
For use of this form, see AR 600-85; the proponent agency is DCS, G-1.
criminal justice system status changes to
1.
SECTION A - CONSENT
I, do hereby voluntarily consent to the release of the following information by pertaining to my identity, diagnosis, prognosis, or treatment from any Army record maintained in connection with alcohol or other drug abuse education, training, treatment, rehabilitatiton, or research to
, this day of , (client's full name)
(name of installation ADAPCP) for the purpose of namely, (extent or nature of information to be disclosed)
SECTION B - EXPIRATION/REVOCATION
(Check applicable paragraph)
- Or - (For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b(4)(b) and 6-10e(3), AR 600-85)
2. I understand that this consent automatically expires 60 days from today's date or when my present
SECTION C - APPROVAL AUTHORITY FOR RELEASE OF INFORMATION
In my judgment, the release of an evaluation of the present or past status of (client's name) in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her.
DA FORM 5018-R, NOV 1981 APD LC v3.00ES
NOTE:
I understand that this consent automatically expires when the above disclosure action has been taken in
Other than the MEDCEN/MEDDAC Commander, approval authority for release of information may be delegated to the Program Physician or the Clinical Director.
Further, I understand that if my release from confinement, probation, or parole is conditioned upon my participation in the ADAPCP, I cannot revoke this consent until there has been a formal and effective termination or revocation of my release from such confinement, probation, or parole.
reliance thereon and that, except to the extent that such action has been taken, I can revoke this consent at any time.
SIGNATURE OF CLIENT
DATE
NAME OF WITNESS (
Type or print)
SIGNATURE
DATE
NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE
(Type or print)
DATE
SIGNATURE
ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION
For use of this form, see AR 600-85; the proponent agency is DCS, G-1.
criminal justice system status changes to 1.
SECTION A - CONSENT
I, do hereby voluntarily consent to the release of the following information by pertaining to my identity, diagnosis, prognosis, or treatment from any Army record maintained in connection with alcohol or other drug abuse education, training, treatment, rehabilitatiton, or research to , this day of (client's full name) (name of installation ADAPCP) for the purpose of namely, (extent or nature of information to be disclosed)
SECTION B - EXPIRATION/REVOCATION
(Check applicable paragraph)
- Or - (For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b(4)(b) and 6-10e(3), AR 600-85) 2.
I understand that this consent automatically expires 60 days from today's date or when my present
SECTION C - APPROVAL AUTHORITY FOR RELEASE OF INFORMATION
In my judgment, the release of an evaluation of the present or past status of (client's name) in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her.
DA FORM 5018-R, NOV 1981
APD LC v3.00ES
NOTE:
I understand that this consent automatically expires when the above disclosure action has been taken in Other than the MEDCEN/MEDDAC Commander, approval authority for release of information may be delegated to the Program Physician or the Clinical Director.
Further, I understand that if my release from confinement, probation, or parole is conditioned upon my participation in the ADAPCP, I cannot revoke this consent until there has been a formal and effective termination or revocation of my release from such confinement, probation, or parole.
reliance thereon and that, except to the extent that such action has been taken, I can revoke this consent at any time.
3.00
DA FORM 5018-R, NOV 1981
ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION
APD
| NAME: |
| DAY: |
| MONTH: |
| FY: |
| INSTLNA: HQDA ASAP |
| RESRCHTO: Child/Youth Svcs Suitability Prog |
| RESEARCH: |
| RESEARCHA: completing a background check requirement in accordance with |
| RESEARCHB: Department of Defense Instruction 1402.05 and Army Directive 2014-23. |
| RESEARCHC: |
| RESEARCHD: |
| EXTDSCLa: |
| NAMELY: *** see above*** |
| XONE: |
| XTWO: |
| CRJSSYSA: |
| CRJSSYSB: |
| signature_BUTTON1: |
| CLIENTDTE: |
| WTNSNAME: |
| signature_BUTTON2: |
| WTNSDTE: |
| NACLIENT: |
| A: |
| DRDTE: |
| signature_BUTTON3: |
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