ac-form-43-africom-medical-waiver-request-form-15-jan-2019.pdf

USAFRICOM Medical Waiver Request Using encrypted email, send this form and all scanned documentation to email address identified in ACI 4200.09A, Enclosure D.

For assistance DSN Contact Phone Numbers: AFAFRICA: 314-480-4698; CJTF HOA: 311-824-4282; MARFORAF:

65; NAVAF: 314-626-4690; SOCAFRICA: 314-421-3474; USARAF: 314-637-8371; USAFRICOM HQ: 314-421-2263.

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314-431-35 nt Name (Last, First): DOB: SSN (last 4):

Sex: Rank/ Grade: Service:

oyment/Travel Date: Travel Duration (days): Destination (country):

/AFSC/Skill Identifier/Job Description: Home Station/Unit:

e/R eserve/C ivilian/C ontracto r:

ester

POC(Medical Personnel)N ame/E-ma il/Phone:

ired documentation for waiver evaluation in addition to this form:

orm 2766, Adult Preventive and Chronic Care Flow sheet, with full medical history including all medical conditions, surgeries, medications, and ary of Deployment Limiting Condition(s). DoD Civilians/Contractors who are age 40 and older must have a 10-year atherosclerotic vascular disease (ASCVD) risk percentage calculated. (http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/)

Summary (To be completed by healthcare provider): Include all clinically relevant information necessary to make a disposition ing, but not limited to: Diagnosis (ICD-10), history of the condition, date of onset, prior treatments, current treatments, limitations imposed by the tion and/or medications, prognosis, and required follow-up. (Use additional sheets, if needed. The more clinical information provided, the better.)

lemental documentation (include information relevant for deployability determination):

ecialty consults results establishing diagnosis, treatment, oring plan and prognosis.

cent and relevant surgery, laboratory, pathology and tissue ination reports.

ports of studies (radiographs, pictures, films or procedures).

d. Summaries and past medical documents (e.g. hospital summary).

e. Reports of proceedings (e.g. Tumor Board, Medical Evaluation Boards, etc.)

f. Job requirements (physical condition, exertion level, etc.)

e reviewed the case summary and hereby submit this request der’s ture: Date:

-------------------------------------------------------------- FOR SURGEON’S OFFICE USE ONLY ---------------------------------------------------------------------er Approved: YES NO er ority ture: Date:

ments:

STAMP / PRINTED NAME AND TITLE

STAMP / PRINTED NAME AND TITLE

mary of medical condition(s):

erstand the potential risks associated with this deployment limiting condition. For this individual, I am requesting a waiver of the h requirement for travel to the USAFRICOM Area of Operation.

ander or nee ture: Date: STAMP / PRINTED NAME AND TITLE fficial Use Only: This document may contain information exempt from mandatory disclosure under the Freedom of Information Act (FOIA) of 1986 {Public Law 99-570, 5 USC )}. This information is also protected by the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA) of 1996 {Public Law 104-191} and any enting regulations. It must be safeguarded from any potential unauthorized disclosure. If you are not the intended recipient, please contact the sender by reply e-mail and permanently destroy all copies of the original message. Unauthorized possession or disclosure of protected health information may result in personal liability for civil and federal criminal penalties.

FORM 43, 15 January 2019 UNCLASSIFIED mailto:africom.stuttgart.acsg.mbx.j004-force-health-protection@mail.mil