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Patient Resources

Forms

Irwin Army Community Hospital-Riley Forms

Freedom of Information Act
FOIA Request Form
Patient Records
DD Form 2870 - Authorization for Disclosure of Medical or Dental Information

DA Form 5018-R - ADAPCP Client's Consent Statement for Release of Treatment Information

PAD Form

Radiology ROI (Non-Referral related)

DD Form 2870 - Appointment-Based Requests
Public Health
Fort Riley Water Inspection Form

Fort Riley Water Trailer Certification Guide

Pediatric and Adult Influenza Screening and Immunization Documentation
School & Sports Physicals
Child Medical Record Immunization History & Health Assessment Form

Child & Youth Services Sports Physicals Form

KSHSAA Sports Physical Form Rev 3/2024
Travel Documents
DTS Profile – Data Entry Form

DD 1351-3 - Statement of Actual Expenses

Confirmation of Specialty Care Form
Women's Health
OB Intake Paperwork
Third Party Collection Program/Medical Services Account/Other Health Insurance

Defense Health Agency Forms

TRICARE Forms

Download a TRICARE Form

Submit

Don't forget to keep your family's information up-to-date in DEERS.