AF Form 565: Record of Inpatient Treatment – Download Now

AF Form 565: Record of Inpatient Treatment – Download Now – AF Form 565: Record of Inpatient Treatment (DD Form 2005 Privacy Act Statement Serves) is a specialized Air Force medical form used to document inpatient care provided at military treatment facilities (MTFs). It serves as part of the official inpatient treatment record for active duty personnel, dependents, retirees, and other eligible beneficiaries under the Military Health System (MHS).

This article explains the form’s purpose, how it fits into Air Force and DoD medical record-keeping, who uses it, and where to download the official version. It is intended for U.S. service members, veterans, military families, and medical administrators seeking accurate, up-to-date guidance on Air Force inpatient documentation.

What Is AF Form 565?

AF Form 565, titled Record of Inpatient Treatment, is an Air Force-specific form designed to capture essential details of a patient’s hospital admission and inpatient stay. It is often referenced alongside DD Form 2005 (Privacy Act Statement – Health Care Records), which provides the required Privacy Act notice and is incorporated into or serves with the inpatient record process.

The form helps standardize documentation of inpatient episodes, supporting continuity of care, medical readiness, disability evaluations (such as Medical Evaluation Boards or MEBs), line-of-duty determinations, and long-term record retention.

Key points:

  • It is not a general consent form but part of the structured inpatient record jacket used in Air Force MTFs.
  • It complements other standard forms like SF 502 (Narrative Summary), SF 509 (Progress Notes), and various DoD inpatient documentation requirements.
  • The associated DD Form 2005 (June 2016 edition) is a blanket Privacy Act Statement that applies to all requests for personal information in MHS health care settings. It explains authorities (e.g., 10 U.S.C. Chapter 55), principal purposes (treatment, eligibility, claims, fitness for duty), and routine uses under HIPAA and DoD policies. Care is not denied if the statement is provided.

Purpose of AF Form 565 in Air Force Medical Records

Inpatient records document care requiring at least one overnight stay in a hospital or clinic. AF Form 565 helps create, maintain, and transfer these records in accordance with DoD and Air Force policies, including DHA-PM 6025.02 (DoD Health Record) and relevant Air Force manuals (e.g., DAFMAN 48-108).

Primary uses include:

  • Recording admission, treatment course, discharge, and key clinical events during inpatient stays.
  • Supporting Medical Evaluation Board (MEB) processes for conditions affecting fitness for duty (often required for ARC members alongside AF Form 348 or DD Form 261 for line-of-duty determinations).
  • Facilitating record transfer between MTFs, to the National Personnel Records Center (NPRC), or for veterans’ benefits claims.
  • Ensuring compliance with privacy, retention, and disposition rules (inpatient records are typically retained for extended periods—often 50 years after cutoff in certain cases).

In the broader DoD Health Record, inpatient documentation is distinct from outpatient/ambulatory records and includes elements like history, physical exams, progress notes, operative reports, and discharge summaries.

Who Uses AF Form 565 and When Is It Required?

  • Primary users: Air Force Medical Service personnel at MTFs, including physicians, nurses, medical records administrators, and Physical Evaluation Board Liaison Officers (PEBLOs).
  • Patients: Active duty Air Force members (including Air Reserve Component), dependents, retirees, and other TRICARE-eligible beneficiaries receiving inpatient care.
  • Key scenarios:
    • Hospital admission for illness, injury, surgery, or observation.
    • Preparation of inpatient record jackets for teaching or fixed facilities.
    • MEB/Integrated Disability Evaluation System (IDES) processing.
    • Transfer or retirement of medical records.

The form is referenced in contexts like ARC medical continuation and disability processing, where complete inpatient documentation is critical.

How AF Form 565 Fits Into the Inpatient Record Process?

According to DoD guidance, inpatient records include a standardized set of documents filed in a specific order within the record jacket. AF Form 565 contributes to the chronological and summary aspects of the stay.

Typical inpatient record components (Air Force context) may include:

  • Admission and discharge summaries.
  • History and physical examination.
  • Progress notes and nursing documentation.
  • AF Form 565 as the dedicated Record of Inpatient Treatment.
  • Privacy Act acknowledgment via DD Form 2005.
  • Other supporting forms (e.g., anesthesia, consent, lab results).

Records are managed per service-specific jacket formats and retired to the NPRC after cutoff periods (e.g., 5 years for some teaching facilities, with longer destruction timelines). Requests for older inpatient records often require the MTF name and year of treatment.

Note on DD Form 2005: This one-page form is signed by the patient or sponsor and becomes a permanent part of the health care record. It covers collection of SSN and other data under multiple U.S. Code authorities and explains permitted uses/disclosures for treatment, payment, operations, and other routine purposes.

Official Air Force forms are available through the Air Force e-Publishing site.

Direct download links provided:

For the latest official versions and instructions:

  • Visit the Air Force e-Publishing portal (e-publishing.af.mil) and search for AF Form 565.
  • DD Form 2005 is available from the Executive Services Directorate (ESD) or DoD forms management: https://www.esd.whs.mil/Directives/forms/.

Always use the most current edition from .mil sources to ensure compliance. Forms may be filled electronically or printed as needed within MTF systems.

Accessing your own records:

  • Active patients: Use the MHS GENESIS Patient Portal or TRICARE Online.
  • Veterans/retirees: Contact the relevant MTF (if recent) or submit requests to the National Personnel Records Center (NPRC) or AFPC for personnel-related medical documentation. Inpatient records are typically identified by MTF and year.

Important Considerations and Privacy

All handling of AF Form 565 and associated records must comply with the Privacy Act of 1974, HIPAA (as implemented in DoD), and DoD 6025.18-R. DD Form 2005 ensures patients are informed of their rights and the purposes for which information is collected and may be disclosed.

Protected health information (PHI) is used primarily for treatment but may support benefits adjudication, fitness evaluations, third-party liability, or program oversight. Disclosures outside routine uses generally require authorization (e.g., via DD Form 2870).

Medical records administrators should follow current DHA and Air Force instructions for creation, filing, maintenance, transfer, and disposition of inpatient records.

Conclusion: Why Proper Use of AF Form 565 Matters?

Accurate completion of AF Form 565 – Record of Inpatient Treatment ensures high-quality documentation that supports patient care, medical readiness, disability processing, and long-term benefits for Air Force personnel and families. Paired with the DD Form 2005 Privacy Act Statement, it helps maintain compliance while protecting sensitive health information.

For official use, always consult the latest guidance from Air Force Medical Service, DHA-PM 6025.02, and e-publishing.af.mil. If you need to request copies of inpatient records, include the specific MTF and year(s) of treatment for faster processing.

Download the form here:

Stay informed by checking official .mil sources regularly, as forms and policies are subject to updates.

This article is for informational purposes only and is based on publicly available DoD and Air Force references. It is not a substitute for official medical or legal advice. Contact your MTF medical records department or appropriate command for specific guidance.