Security Levels

National Terrorism Advisory System (NTAS) check current status
Health, Safety and Work-Life Directorate

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 3/12/2014