Forms

Please complete all Highlighted areas that apply, be sure to sign and place todays date on the back of the form.  Each Family member (other than the Active Duty sponsor) needs to have a DD 2569 Other Health Insurance Form completed annually, or when there are changes to your Other Health Insurance information.  When turned in, you will receive a Yellow Card as verification of meeting the  annual requirement for DD 2569.  The Yellow Card will expire one year from the date of completing the DD 2569.  Please bring the Yellow Card to present at each visit, including picking up or dropping off pharmacy.  Drop off your completed form at the MTF to receive your Yellow Card.

1 - Print the request form,  fill out and fax or email to Pad.
2 - Fax:  630-570-5895
      Email:  6305705895@amedd.labusa.com
3 - We will complete the request and upload into DOD Safe for the beneficiary to pick up with a valid email and download to their personal computer, disc or jump drive.  If they do not have an email and it is NOT and emergency we will send via US Mail.

1 - Print "REQUEST COMPLETE COPY OF RECORDS" form DD 2870, fill out and fax or email to Pad
2 - Fax:  630-570-5895
      Email:  6305705895@amedd.labusa.com
3 - We will complete the request and upload into DOD Safe for the beneficiary to pick up with a valid email and download to their personal computer, disc or jump drive.  If they do not have an email and it is NOT and emergency we will send via US Mail.
4 - Complete copies is approximate 6 week waiting

1 - Print the "RELEASE FROM OUTSIDE PROVIDER" form,  fill out and fax or email to Pad. 
2 - Fax:  630-570-5895
      Email:  6305705895@amedd.labusa.com
3 - We will complete the request and scan into Medical Record when received

Service member will not need to come to PAD for in-processing.  They will be registered via telephonically or Alpha Roster sent from Unit (or bldg. 513 staff duty personnel for all TDY for Schools SM's).  Service Member needs to ensure telephone number is clear and legible.  Please send roster to usarmy.rucker.medcom-lahc.list.release-of-information@mail.mil

To request to initiate LOD please print and complete the LOD Processing document.  Scan the document and email usarmy.rucker.medcom-lahc.list.release-of-information@mail.mil or fax to 630-570-5895 . Once received we will process and send to unit Commander for review and signature.