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Cover Page
Prior Versions No Longer Valid
APP 03-2020
APPLICATION FOR
ADMISSION
Dear Applicant:
Please complete the following steps:
1. Submit all of the required forms including the Ap-
plication, Medical Examination, and Functional
Assessment.
2. Submit Military Documentation to verify eligibil-
ity.
3.
If requested by AFRH or if applicant is aware of
cognitive or psychiatric medical history, sub
mit a
Mental Health Evaluation. This form is only re-
quired if AFRH requests the exam. (A request does
not necessarily result in a denial of residency; it is
merely a request for additional information.)
4. Submit financial information included in this ap-
plica
tion along with documentation requested on
the pre-admissions checklist. If additional infor-
mation is required, a member of the business of-
fice will contact the applicant.
5.
If approved, the admissions officer at the campus
selected will call and set up a re
port date and let
you know what to bring with you upon arrival.
If you receive notification that your application has
been approved, you must wait until the Admissions
office arranges an official report date with you.
Do
not make moving arrangements without an official
report date, please.
Thank you
AFRH
RETURN APPLICATION TO:
ARMED FORCES RETIREMENT HOME
PUBLIC AFFAIRS OFFICE #584
3700 NORTH CAPITOL ST, NW
Washington, DC 20011-8400
Fax Number: (202) 541-7519
Telephone: (800) 422-9988
If FAXING documents to AFRH, please make a
black & white copy before sending the fax so
that it will be legible when it arrives. Please call
and let us know to look for the documents to
come through as well – Thank you for all your
help! We want to prevent any delays in pro-
cessing applications.
APP
ARMED FORCES RETIREMENT HOME
Cover Page
Prior Versions No Longer Valid
APP 03-2020
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C 136, Under Secretary of Personnel and Readiness; 24 U.S.C. 401, Armed
Forces Retirement Home; DoD Directive 5124.09 Assistant Secretary of Defense for Personnel
and Readiness Force Management; DoD Instruction 1000.28, Armed Forces Retirement Home
(AFRH); and E.O. 9397 (SSN), as amended.
PURPOSE: To determine and verify eligibility for admission to the AFRH.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of
the Privacy Act of 1974, as amended, the records contained herein may specifically be disclosed
outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: To the Federal Re-
serve for processing the debt on the resident account; To authorized contractors or vendors for
the purpose of providing medical services to the residents of the Armed Forces Retirement
Home; To any Federal agency which provides medical services to residents of the Armed Forces
Retirement home; To the Inspector General of the Department of Defense or his/her designee,
for conducting inspections of AFRH records; To a Federal agency, or an organization or person
contracting with the AFRH for information needed in the performance of official duties related
to reconciling or reconstructing data files, compiling descriptive statistics, and/or making analyt-
ical or financial studies to support the function for which the records were collected and main-
tained; Law Enforcement Routine Use; Congressional Inquiries Disclosure Routine Use; Disclo-
sure of Information to the National Archives and Records Administration Routine Use; Disclosure
to the Merit Systems Protection Board Routine Use; and Data Breach Remediation Purposes Rou-
tine Use.
The applicable system of records notice is DPR 38 DoD, Armed Forces Retirement Home elec-
tronic Resident Information System (eRIS) and is available at: (ADD LINK WHEN PUBLISHED).
DISCLOSURE: Voluntary; however, failure to provide the required information may result in the
delay or denial of admission.
Warning: Please print and MAIL or FAX your application documents to the Public Affairs Office.
Information in this application is Protected Personal Information and should not be sent elec-
tronically without proper protection in place (such as password protection). Emailed documents
are more vulnerable to unintended disclosure to inappropriate recipients if not protected. Please
call the Public Affairs Office and speak to a representative if you have any questions regarding
the proper procedures for submitting applications to AFRH at 800-422-9988.
MAIL TO: (preferred method for shipping – USPS: United States Postal Service)
Armed Forces Retirement Home
Public Affairs Office Box #584
3700 North Capitol St, NW
Washington, DC 20011-8400
FAX TO: (please call first to confirm that a PAO representative is prepared to receive fax)
Public Affairs Office (202) 541-7698 or (202) 541-7551 8am – 5pm EST
Application for Admission
For Employee Use
(a)
PAO : ___________
Report: ___________
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APP 03-2020
Date Submitted: __________________________ Anticipated Entry: __________________________
Applicant is a: Former Member of the Armed Forces Eligible Spouse of a Retired Veteran
How did you learn about AFRH? (Which publication, referral from someone, etc.)
If either of the statements below is false, please call AFRH to discuss before completing the remainder of this application.
Applicant is able to complete activities of daily living without assistance from others. TRUE FALSE
Applicant has never been convicted of a felony. TRUE FALSE
Application for: Gulfport, MS Washington, DC If either, 1
st
Choice: GP DC
Applicant was a: Former Resident Former Applicant Applied when? _______________
At which Location? Gulfport, MS Washington, DC Resident when? _______________
Reason for decision to discharge from AFRH if you were a resident previously?
family circumstances financial reasons medical issues other reason: _______________
Select any of the following statements which are true for the veteran applying:
Retired with 20 or more years of Active Service Retired Early or from the Guard/Reserves
Veteran is at least 60 years old Served during wartime (not in a war theater)
Receiving benefits for a service-connected disability Served in a hostile zone during wartime
Has disability or illness unrelated to military service Served in a women’s component during WWII
PERSONAL PROFILE
First Name
Middle Name
Maiden Name (if applicable)
Last Name
Street
City
State
Zip Code
Social Security Number
Birthdate
Age
Birthplace
Email
Telephone (home/landline)
Telephone (mobile)
Male Single Widowed Married Both Veteran & Spouse applying together
Female Divorced Separated Spouse’s Name:
Where have you lived most of your life?
Participation in any Military Associations?
Highest grade level:
College experience or degree?
Military Profession:
Civilian Profession/s:
Hobbies/Interests:
Community service activities?
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Fix Address
ARMED FORCES RETIREMENT HOME
Application for Admission
Name: __________________
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APP 03-2020
CONFIRM ELIGIBILITY: ELIGIBILITY FOR QUALIFIED MEMBERS OF THE ARMED FORCES
Persons, MALE or FEMALE, who served as members of the Armed Forces, at least one-
half of whose service was not active commissioned service (other than as a warrant
officer or limited-duty officer), are eligible to become residents of AFRH:
SELECT PRIMARY FORM OF SERVICE: Enlisted Warrant Officer (WO) Limited Duty Officer (LDO)
PLEASE SELECT ALL OF THE CATEGORIES THAT APPLY:
CATEGORY 1: Persons who are 60 years of age or over and were discharged or released from service in the
Armed Forces after 20 or more years of active service.
CATEGORY 1(a): Spouses may be admitted with sponsor veteran if the spouse was a covered beneficiary at
the time of the veteran’s retirement, within the meaning of section 1072(5) of title 10, USC.
Note: The spouse of an active-duty Retiree must submit proof of eligibility by providing a copy of the
marriage certificate showing that the couple was married at the time of the veteran’s retirement after
20 years of ACTIVE service and is a covered beneficiary registered with Defense Enrollment Eligibility
Reporting System (DEERS). Beneficiary spouses are not eligible to apply individually without the sponsor.
CATEGORY 2: Persons who are determined under rules prescribed by the Chief Operating Officer to be suffering
from a service-connected disability incurred in the line of duty in the Armed Forces.
CATEGORY 3: Persons who served in a war theater during a time of war declared by Congress or were eligible
for hostile fire special pay under section 310 or 351 of title 37, United States Code, and who are determined
under rules prescribed by the Chief Operating Officer to be suffering from injuries, disease, or disability.
CATEGORY 4: Persons who served in a women’s component of the Armed Forces before June 12, 1948 and are
determined under rules prescribed by the Chief Operating Officer to be eligible for admission because of com-
pelling personal circumstances.
ALL APPLICANTS MUST ALSO MEET THE FOLLOWING REQUIREMENTS:
• Applicants must never have been convicted of a felony and are subject to a background check.
• Applicants must be honorably discharged or released from military service.
• Applicants with substance abuse or mental health problems are NOT ELIGIBLE except upon a judgement and
satisfactory determination by the Chief Operating Officer that the Retirement Home is able to accommodate
the person’s condition and that the person agrees to and abides by such conditions of residency as AFRH may
require.
• At the time of admission, all applicants must be PHYSICALLY AND MENTALLY ABLE TO LIVE INDEPENDENTLY.
Specifically, they must be able to tend to their own personal needs, attend a central dining facility for meals,
keep all medical appointments and make reasonable decisions regarding own healthcare, finances, and safety
without assistance from others. If an increased level of care is needed after being admitted, assisted living, long
term care and memory care are available at both campuses.
• Applicants must maintain acceptable healthcare coverage in order to be eligible for residency. If eligible for
Medicare, it is required that residents have Part A, Part B, and Supplemental Coverage. Residents who are not
eligible for Medicare must either have a medical insurance plan which covers hospitalization, medical treat-
ments, durable medical equipment, prescriptions, and transportation; or they must have 100% healthcare ben-
efits through the Department of Veterans Affairs. Pharmaceutical insurance is required at upper levels of care.
Residents in assisted living, memory support, or long term care will either need to acquire or have prescription
coverage in place.
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ARMED FORCES RETIREMENT HOME
Application for Admission
Name: __________________
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APP 03-2020
MILITARY SERVICE VERIFICATION
Select all applicable military branches: USA USN USAF USMC USCG USSF
Submit copies of the following documents for verification of military service:
DD-214’s (required) Veterans Affairs Benefit Verification Letter (required)
Discharge Certificate Military Statement of Service
NAVPERS 563 WD AGO 53-55
To obtain proof of military service, write to National Personnel Record Center, 1 Archives Dr., St. Louis, MO 63138 or
To request and download your benefit letter or military records, go to www.va.gov to obtain documents through milConnect
Please check here if your records were damaged in the NPRC fire in 1973 and will be submitting records other than the DD-214 to
verify your military eligibility for residency. Records primarily effected were USA 1912-1960 or USAF 1917-1964 with surnames H-Z.
Legal Name on the DD-214
Military Service Number
DoD ID# / DEERS# (on front of the Military ID)
Initial Branch of Service
Date of Entry
Place of Entry
Final Branch of Service
Date of Separation
Place of Discharge
Total ACTIVE Service (all Periods & Forces)
Active Duty Retired (20+ years):
Character of Service:
YR MO DY
Yes No Honorable Other:
Total INACTIVE Service (Guard/Reserve)
Retired Reserve/Guard (20+ years):
NGR ordered to Active Service or for National Emergency
YR MO DY
Yes No Reason:
Total Commissioned Service (if applicable)
Final Pay Grade:
Final Grade, Rate, or Rank:
YR MO DY
Did you serve during a time of war declared by Congress or did you qualify for special hostile fire pay?
WWII 1939-1945 Korea 1950-1953 Grenada 1983 Afghanistan 2001-Present
Iraq 2003-2011 Vietnam 1955-1975 Gulf War 1990-1991 Other: ________________________
If you served during wartime, how would you describe the nature of your service?
Served in country or declared hostile zone/waters Served as support (outside of hostile zone)
Where and when? ___________________________________________________________________________________
Are you a recipient of any service medals or awards?
Medal of Honor Silver Star Bronze Star
Purple Heart Service Cross Distinguished Service Medal
Other Awards: ___________________________________________________________________________________
Were you a POW? Yes No Wounded Warrior Program? Yes No
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ARMED FORCES RETIREMENT HOME
Application for Admission
Name: __________________
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APP 03-2020
ELIGIBLE SPOUSE APPLYING FOR RESIDENCY (skip this section if applying as an individual):
Did you also serve as an enlisted member of the Armed Forces yourself? Yes No
Are you eligible for residency as a veteran in your own right? Yes No
Are you applying as the dependent spouse of a veteran with 20 years of active service? Yes No
Name of the Veteran sponsor: ______________________________________ (on the beneficiary’s Military ID)
Beneficiary’s DoD ID / DEERS #: ______________________________________ (box on front side of Military ID)
Total Active Service time: ______________________________________ (exceeds 20 years of active service)
Date of Marriage: ______________________________________ (submit Marriage Certificate copy)
Date of Retirement: ______________________________________ (verified on sponsor’s DD-214)
INSURANCE VERIFICATION – For All Applicants
MANDATORY: Every applicant must provide proof of Major Medical Insurance coverage or healthcare benefits: Please
provide a
COPY OF ALL OF YOUR INSURANCE ID CARDS with your application. If you have Tricare – send a copy of your MILITARY ID
as proof of coverage. If you have VA Benefits, the S
UMMARY OF BENEFITS LETTER must show that you are qualified for 100%
service-connected disability or 100% unemployability rating if using VA benefits in place of supplemental insurance. Persons
with less than 100% benefits from the VA will need to have additional insurance to satisfy this requirement. Individuals are
responsible for payment of any deductibles, co-pays, and other non-covered costs associated with medical services.
Eligible for Medicare (over age 65): Insurance premium payments for Medicare & Supplements are deductible for AFRH fee assessment
Enrolled in Original Medicare – Mandatory Effective Date: ______________________
a. Medicare Part A: hospital insurance
b. Medicare Part B: medical insurance (ALL applicants eligible for Medicare must enroll in Part B)
Premium
$________
Medicare Supplemental (wrap-around) coverage is required for all residents eligible for Medicare:
a. Supplemental benefits: 100% VA Healthcare Benefits for a service-connected disability
b. Supplemental policy: Medicare Part C / Medicare Advantage or Medicare Supplement Plan
Insurance Company: ___________________________________________
c. Supplemental TRICARE: (Tricare is only available for Military Retirees & their beneficiaries)
Tricare for Life
Tricare Prime/Select/Retired Reserve
Tricare USFHP Family Health Plan (available in DC only)
Premium
$________
$________
Medicare Pharmacy Benefits: Please let us know if you already have supplemental pharmacy coverage. You
will eventually need to have drug coverage in place if transferred into advanced levels of
care (AL, LTC, & MS).
*Call your insurer, if you are unsure whether your present coverage will include prescription drugs in the upper levels of care.
a. Medicare Part C (Medicare Advantage plans with drugs – MAPD prescription coverage will continue at upper levels)
b. Medicare Part D (Needed in addition to some insurance plans or when relying on 100% VA Benefits for coverage)
c. Other insurance:
_________________________________________________________________________________
Premium
$________
Not Eligible for Medicare (under age 65):
Residents who are not eligible for Medicare are required to have and maintain creditable healthcare insurance which
covers hospitalization, medical treatments, durable medical equipment, prescriptions, and transportation at their own
expense; or they must have 100% VA Healthcare Benefits.
a. Tricare Prime/Select/Retired Reserve or Tricare USFHP Family Health Plan (available in DC only)
b. Major Medical Insurance (i.e. Private, Federal, RR, employer, etc.) INSURANCE
c. Public Medicaid or Healthcare Market Place Insurance (Obama Care) COMPANY:
d. 100% VA Benefits for service-connected disability (veteran must use VA or DoD/MTF facilities for healthcare)
Other types of healthcare insurance: Premium
a. Dental Insurance Company: _____________________________ $ _____________
b. Vision Insurance Company: _____________________________ $ _____________
c. Other ___________________ Company: _____________________________ $ _____________
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ARMED FORCES RETIREMENT HOME
Application for Admission
Name: __________________
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APP 03-2020
FINANCIAL AND OTHER INFORMATION
Disability Benefits Do you require a service dog for a disability? No Yes: additional information is required
VA Disability benefits awarded for service-connected conditions incurred during active-duty service in the military
AMOUNT / MONTH
Yes No
VA Service-Connected Disability
Percentage Rating: %
$
VA Disability benefits only available to Military Retirees for service-connected conditions incurred during combat
Yes No
CRSC: Combat-Related Special Compensation $
Disability benefits only available for low-income disabled veterans who served in wartime (any disability, it doesn’t have to be a SCD)
Yes No
VA Pension PLEASE NOTE: This is not the same thing as retirement pay $
Social Security benefits for individuals who are permanently disabled and no longer able to work (if eligible)
Yes No
SSDI: Social Security Disability Benefits
Condition:
$
Income Verification
Submit copies of all 1099s, W-2s, DFAS statements, and Bank Statements
AMOUNT / MONTH
Yes No
Social Security Benefits Early retirement (Age 62)? Yes No
$
Yes No
Military Retirement Pay (DFAS)
$
Yes No
Civil Service Retirement/Annuity CSA#:
$
Yes No
Other Retirement Income: IRAs, TSPs, Retirement, Pension, Annuity, etc.
PLEASE NOTE: Include RMD (required minimum distribution) if over age 70.5 in retirement income (Annual ÷ 12)
$
Yes No
Earned Income: employment, contracts, businesses, or services offered
$
Yes No
Income from Rental Property, Gambling, or other sources
$
Yes No
Investments, Dividends, or other interest income
$
Yes No
Other sources of taxable income:
$
Yes No
Other sources of non-taxable income:
$
Financial Management
Do you manage your own financial affairs? Yes No Do you file income tax returns? Yes No
Do you have a Living Will/Advance Directive? Yes No Last two tax returns filed:
Do you have pre-arranged pre-paid Funeral
Plans?
Yes No IRS Filing status? Individual Joint/Head of Household
Do you have a Conservator, Power of Attor-
ney, or Guardian for your affairs?
Yes No
Do you have any ongoing legal obliga-
tions such as a divorce or otherwise?
Yes No
Do you have a Last Will and Testament? Yes No Any court ordered support payments?
$
Automobile Insurance:
If you intend to bring a vehicle with you to AFRH, it is required that all residents maintain registration, automobile insurance, and current
driver’s license in order to be issued a parking permit or to drive on campus. Once you move to AFRH, you will need to update your
residency on each of these documents.
Do you intend to bring a vehicle with you to AFRH if accepted as a resident? Yes No
Driver’s License # ___________________________ State: _____ Insurance Company: _____________________________
Disability
Income
$$ Mgmt
ARMED FORCES RETIREMENT HOME
Application for Admission
Name: __________________
Page 6 of 12
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APP 03-2020
CONTACT INFORMATION AND FAMILY PROFILE
Please submit copies of documents with your application if you have a POA or other guardianship in place.
Legal Representative
NAME
CONTACT INFOMATION
Power of Attorney (POA):
Financial Power of Attorney:
Healthcare Power of Attorney:
Conservator / Guardian:
Executor of Estate
Relationship
First
Middle and Maiden Name (if applicable)
Last
Father
☐ Deceased
Mother
☐ Deceased
Spouse
☐ Deceased
Relationship
Name
Address
Contact information:
Child 1
Child 2
Child 3
Other
(attach a list if more space is needed)
The name(s) listed below are family members or friends to whom I grant permission for the Armed Forces Retirement
Home and its representatives, using their best judgment, to verbally discuss my application, finances, and/or healthcare
and grant them permission to disclose information that is relevant to my application.
Relationship
NAME
CONTACT INFOMATION
Please indicate any information that you do not wish for AFRH to discuss with the aforementioned persons:
Signature of the Applicant
Date
ARMED FORCES RETIREMENT HOME
Application for Admission
Name: __________________
Page 7 of 12
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APP 03-2020
FINAL CERTIFICATION
I certify that the information in this application is accurate and factual to the best of my
knowledge. I fully understand that any intentional incorrect information or omission in
my application may result in disapproval or if discovered after approval, may be reason
for discharge from the Armed Forces Retirement Home (AFRH).
Signature of the Applicant
Date
I hereby authorize the release of my military and medical records from any civilian or U.S.
Government source to the AFRH.
Signature of the Applicant
Date
Anyone (other than the applicant), who has assisted in the preparation of this application
must also sign below. A second signature is necessary if the applicant did not fill out the
application by themselves.
Name of the person assisting: __________________________________________
Relationship to the applicant: __________________________________________
Preparer/Assistant’s Signature
Date
PRIVACY ACT STATEMENT
The information solicited on this form is authorized by Title 24, United States Code, and
Section 412(c). The primary purpose for the information is to determine and verify eligi-
bility for admission to the AFRH. The information is given on a voluntary basis, but failure
to provide the information requested may result in denial of admission. The information
provided will be used by AFRH employees and authorized representatives and may be
disclosed as permitted by law outside the AFRH.
ARMED FORCES RETIREMENT HOME
Application for Admission
Name: __________________
Page 8 of 12
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APP 03-2020
MEMORANDUM OF ACKNOWLEDGEMENT
Thank you for submitting your application to the Armed Forces Retirement Home. For
AFRH to process your application, you must acknowledge your understanding that residency is
contingent on your ability to live independently in our dormitory settings. The signed memoran-
dum is required for your application to be considered in order for it to be forwarded to the ad-
mission board.
It is important that you understand that part of the application includes an evaluation of
your ability to live independently. We reserve the right to deny admission if you are deemed
unable to do so. For this reason, we strongly encourage all applicants visit the AFRH prior to
admission to ensure our community fits your needs. Furthermore, it is imperative that the med-
ical examination and functional assessment forms included in the application process are filled
out and they reflect the true level of your ability to live independently.
By signing this acknowledgement, you indicate your understanding that the conditional
approval of your application is not the final determination of acceptance for residency at AFRH.
Final approval for admission is predicated on AFRH's decision to admit you when reporting to live
at AFRH. AFRH reserves the right to delay or deny admission to the Home if it is determined that
you are not able to live independently, if admission may present a risk to the community, or for
any other reason.
Your signature below further acknowledges that upon approval and prior to becoming a
resident, AFRH will conduct a background check on you to ensure that you have never been con-
victed of a felony.
If your application is approved, AFRH will contact you to work on either scheduling your
arrival at the Home or placing your name on a waiting list. Report dates will be assigned in con-
sultation with you and the Admissions Officer at the facility chosen. Any necessary alteration to
a report date, whether initiated by the applicant or AFRH, will be conveyed to the other party as
soon as possible so that appropriate actions may be taken.
Signature of the Applicant
Date
If you have any questions or concerns regarding this memorandum, please contact Armed
Forces Retirement Home Public Affairs Office at 800-422-9988 option 1 or write to:
3700 North Capitol St. PAO#584, Washington, DC 20011-8400
Entry Survey
Name: _______________________________ Anticipated arrival: _________
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APP 03-2020
1. How does your health compare with others your age?
Very healthy Healthier than most Average health Below average health
2. Describe what your current living arrangements are:
Homeowner Rent/Lease Retirement Community Living with family member
3. Do you currently live in a:
House Townhouse Apartment Condo Mobile Home
Other type of home: ________________________________________________________________
4. Which of the following factors are prompting you to apply for residency at this time? (select three)
Difficult to maintain Healthcare needs
High cost of living
La
ck of security
Ready to downsize
Loneliness
Wa
nt community lifestyle
Want more entertainment
5. Have you ever applied to a retirement community before? Yes No
6. Have you ever applied to AFRH or been a resident here? Yes No
7. When determining where you want to live, how important are the following factors?
Extremely
Important
Very
Important
Somewhat
Important
Not
Important
Need to be independent
Want to be near friends
Want to live near my family
Ease of access to medical care
Ease of access to shopping
Want to lower cost of living
Veteran friendly community
Want to live in a different climate
8. How important are the following factors when choosing a retirement community?
Extremely
Important
Very
Important
Somewhat
Important
Not
Important
Location
Onsite Amenities
Activities/Recreation Therapy
Planned Outings/Trips
Onsite Dental/Vision Services
Onsite Medical Clinic/Pharmacy
Clear
Entry Survey
Name: _______________________________ Anticipated arrival: _________
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APP 03-2020
Transportation to medical care
Meal Service (3 daily meals)
Ability to Age in Place
Physical/Occupational Therapy
Social Activities/Services
Cleanliness of facility
Private room & bathroom
Unit features/style
Laundry room (no charge)
Staff (helpful, friendly)
Affordability of advanced care
Local attractions
9. Please let us know which of the following amenities/services offered at AFRH you find appealing
Fitness Center Woodworking Shop Art Studio Spaces Table Tennis
Swimming Pool Library Golf Course Puzzle Room
Bowling Alley Resident Bar & Lounge Leatherworking Bocce Ball Court
Ceramics Studio Shuffleboard Fishing Pond Horseshoes
Computer Center
Theater / Media Center
Bingo
Corn-Hole Toss
Canteen / Café Art or Music lessons Auto Hobby Shop Walking Trails
Chapels Military Celebrations Game Rooms Clubs/ Club Room
Exercise classes Personal nutritionist Podiatry Services Counseling services
Dances/Socials Volunteer opportunities PX/NEX Trips to casinos
Bible Study
Education opportunities
Beach Access
Salon/Barber
10. Do you have any comments or other suggestions you would like to include?
Thank you for taking the time to complete this survey.
Medical Disclosure Form
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APP 03-2020
M
EDICAL
I
NFORMATION
D
ISCLOSURE
F
ORM
:
Patient’s Name:
Street:
City: State: Zip:
Phone: Cell:
Email:
Healthcare provider/s information:
Primary care :
Street:
City: State: Zip:
Phone: Fax:
Email:
Other provider :
Street:
City: State: Zip:
Phone: Fax:
Email:
I grant my permission to disclose information to:
Armed Forces Retirement Home
Attn: Admissions
3700 Capitol Street, NW
Public Affairs Office #584
Washington, DC 20011
Tel: 202-541-7922 Fax: 202-541-7519
Specific information to be disclosed:
Medical Records covering the last 12 months
Insurance records
Drug, Alcohol or Substance Abuse records
HIV/AIDS-Related Information and test results
Patient history and office notes
Billing records
Mental Health records
I understand that release of this information is provided on a voluntary basis in accordance with the Privacy Act Statement Author-
ity: 10 U.S.C 136; 24 U.S.C. 401 (see the following page for a complete version of the Privacy Act) to determine and verify eligibility
for admission to the Armed Forces Retirement Home. I understand that I may revoke this authorization at any time by giving written
notice to AFRH at the aforementioned address. I also understand the revocation of this authorization will not affect any action
taken by AFRH in reliance on this authorization prior to receipt of a written revocation. I acknowledge that failure to provide any
required information may result in the delay or denial of admission to the Armed Forces Retirement Home.
Signature
Date
Medical Disclosure Form
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APP 03-2020
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C 136, Under Secretary of Personnel and Readiness; 24 U.S.C. 401, Armed Forces Retirement
Home; DoD Directive 5124.09 Assistant Secretary of Defense for Personnel and Readiness Force Management;
DoD Instruction 1000.28, Armed Forces Retirement Home (AFRH); and E.O. 9397 (SSN), as amended.
PURPOSE: To determine and verify eligibility for admission to the AFRH.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act
of 1974, as amended, the records contained herein may specifically be disclosed outside the DoD as a routine
use pursuant to 5 U.S.C. 552a(b)(3) as follows: To the Federal Reserve for processing the debt on the resident
account; To authorized contractors or vendors for the purpose of providing medical services to the residents of
the Armed Forces Retirement Home; To any Federal agency which provides medical services to residents of the
Armed Forces Retirement home; To the Inspector General of the Department of Defense or his/her designee, for
conducting inspections of AFRH records; To a Federal agency, or an organization or person contracting with the
AFRH for information needed in the performance of official duties related to reconciling or reconstructing data
files, compiling descriptive statistics, and/or making analytical or financial studies to support the function for
which the records were collected and maintained; Law Enforcement Routine Use; Congressional Inquiries Disclo-
sure Routine Use; Disclosure of Information to the National Archives and Records Administration Routine Use;
Disclosure to the Merit Systems Protection Board Routine Use; and Data Breach Remediation Purposes Routine
Use.
The applicable system of records notice is DPR 38 DoD, Armed Forces Retirement Home electronic Resident In-
formation System (eRIS) and is available at: (ADD LINK WHEN PUBLISHED).
DISCLOSURE: Voluntary; however, failure to provide the required information may result in the delay or denial
of admission.
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Completed 18 July 2020

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