3rd Wed of the Month Training - Closed from 12:00 p.m. – 4:15 p.m.
Oct. 13 - Columbus Day Holiday, Closed all day
Oct 31 - Retiree Health Fair, 8 a.m. - 1 p.m. Yano Hall

Patient Resources

Forms

Lyster Army Health Clinic Forms

DD 2569
- DD 2569 Instructions
  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.
Over the Counter Health Promotion Form
Request Copy of Lab, Rad, and Visit Form
- Instructions
  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.
Request Complete Copy of Records
- Instructions
  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
Release from Outside Provider
- Instructions
  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
877 Medical Records Request
- Instructions
  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.novosel.medcom-lahc.list.release-of-information@health.mil
LOD Processing Form
- Instructions
  To request to initiate LOD please print and complete the LOD Processing document. Scan the document and email usarmy.novosel.medcom-lahc.list.release-of-information@health.mil or fax to 630-570-5895 . Once received we will process and send to unit Commander for review and signature.

DOD Forms

Defense Health Agency Forms

DHA Form 116: Pediatric and Adult Influenza Screening and Immunization Documentation

TRICARE Forms

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Don’t forget to keep your family’s information up to date in DEERS!

Patient Resources

Forms

Lyster Army Health Clinic Forms

DOD Forms

Defense Health Agency Forms

TRICARE Forms

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