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SIGNATURE OF PATIENT/PARENT/GUARDIAN DATE YYYYMMDD RELATIONSHIP TO PATIENT IMPRINT OF PATIENT IDENTIFICATION PLATE WHEN AVAILABLE DA FORM 5006 FEB 2003 DA FORM 5006-R NOV 1996 IS OBSOLETE. USAPA V1. MEDICAL RECORD AUTHORIZATION FOR DISCLOSURE OF INFORMATION For use of this form see AR 40-66 the proponent agency is Office of The Surgeon General* This form will not be used for authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose ...

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