Downloads

Behavioral Health Resiliency Campus

Forms

EACH FORM 62 - 1 Jun 2015

REQUEST FOR BEHAVIORAL HEALTH EVALUATION

Fill out and provide this form to request a behavioral health evaluation.

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Billing

Forms

DD FORM 2569 - 1 Sep 2016

THIRD PARTY COLLECTION PROGRAM, MEDICAL SERVICES ACCOUNT, OTHER HEALTH INSURANCE

You can help make this a reality by completing a Form DD2569 and returning it to us by email or in person at your next visit. Our hospital receives 100% of the funds reimbursed by your civilian health insurance companies to fund additional services, upgrade the facilities and equipment and add programs for our patients. You are not liable for any costs not paid by your civilian insurance to include deductibles cost-shares and co-pays.

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Memoranda

FMR (FAMILY MEMBER RATE) MEMORANDUM - 16 Nov 2017

DIRECT CARE INPATIENT BILLING RATES FOR FY 2018

Department of Defense Uniform Business Office (UBO) Fiscal Year (FY) 2018 Direct Care Inpatient Billing Rates.

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Birthing Center

Forms

OB INTAKE - 1 Nov 2017

The OB Intake form is required prior to your first appointment during pregnancy.

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Fact Sheets

FAMILY CENTERED CARE - 15 Sep 2014

Learn about the Family Centered Care approach.

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NUTRITION FACTS - 15 Sep 2014

The Harvard School of Public Health nutrition guidlines during pregnancy.

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FETAL KICK COUNTS - 12 May 2011

Counting your baby’s movements is an excellent way of knowing that your baby is doing well. Get Fetal Kick Count information and a chart for recording your baby's movements.

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OB ULTRASOUNDS - 12 May 2011

Learn about OB Ultrasounds.

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PREFERRED PREGNANCY MEDICATIONS - 5 May 2011

Over the counter medicaion reccomendations while pregnant.

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Exceptional Family Member Program (EFMP)

Forms

DA FORM 7246 - 1 Jun 2009

EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP) SCREENING QUESTIONNAIRE

This form is used to obtain information needed to evaluate and document the special education and medical needs of family members. This will permit consideration of special education and medical needs of family members in the personnel.

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DA FORM 5121 - 1 Mar 2007

OVERSEAS TOUR ELECTION STATEMENT

This form is used to conduct initial screening of reassignment cycle to determine soldier's eligibility to comply; and (2) basis for initiating specific assignment processing.

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DA FORM 4787 - 1 Mar 2007

REASSIGNMENT PROCESSING

This form is used to make assignment decisions, evaluate family member travel to overseas commands and assign family housing.

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DA FORM 5888 - 1 Sep 2002

FAMILY MEMBER DEPLOYMENT SCREENING SHEET

This form is used to validate family member deployment screening, and to provide gaining command with data to assist in making an assignment decision.

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Memoranda

Sex Offender Declaration For Korea - 17 Apr 2019

Family member declaration to ensure compliance with AR 614-30 Para 3-5a(5).

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EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP) Europe Overseas Memorandum - 29 Nov 2017

To ensure Service Members understand the medical and/or educational documents required for Family travel requests to Europe.

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Checklists

OVERSEAS SCREENING CHECKLIST - 2 Apr 2020

Steps that need to be followed to have a smooth transistion and have your family members added to amended orders.

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Family Readiness Group (FRG)

Memoranda

EACH FRG Informal Fund Standard Operating Procedures (SOP) - 11 Jan 2019

Provide guidelines and procedures necessary to manage the FRG Informal Fund.

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Manuals

Deployment Guide - 16 Mar 2018

A guide to Deployment Readiness

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Flyers

Evans Coloring Contest - 26 Feb 2019

As part of the 2019 Month of the Military Child, the Evans Army Community Hospital command team is asking our military children to let us know how they view their experiences as a part of military life. Theme options include how you viewthe U.S. Military, Military Medicine, or Life as a Military Child.

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MEDDAC FRG Fiscal Year 2019 Calendar of Events - 25 Jan 2019

The MEDDAC FRG events calendar for fiscal year 19.

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Newcomers

Flyers

MEDDAC FRG Fiscal Year 2019 Calendar of Events - 25 Jan 2019

The MEDDAC FRG events calendar for fiscal year 19.

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Checklists

Tips for your next PCS - 1 Apr 2018

A list of PCS “best practices” recommended by Soldiers and their Family.

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Optometry and Ophthalmology

Forms

WARFIGHTER REFRACTIVE EYE SURGERY PROGRAM COMMANDER’S AUTHORIZATION - 18 Dec 2017

This authorization must be turned in prior the the scheduling of the soldier's preoperative appointment.

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PRK & LASIK Application Form - 18 Dec 2017

Warfighter Refractive Eye Surgery Program (WRESP)

Fill out and provide this form to apply for laser surgery.

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Pathology and Laboratory Services

Manuals

LABORATORY SERVICES AND SPECIMEN COLLECTION MANUAL - 25 Jun 2019

Information contained within this manual is provided as a reference for the use of available laboratory services at Evans Army Community Hospital.

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Pediatrics

Forms

DD FORM 2792 (ADDENDUM 3) - 1 Aug 2014

FAMILY MEMBER MEDICAL SUMMARY

Exceptional Family Member (EFMP) Application

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Public Affairs

Forms

DD FORM 2536 - 1 Aug 2007

REQUEST FOR ARMED FORCES PARTICIPATION IN PUBLIC EVENTS

To request a tour of Evans Army Community Hospital, please fill out this form and return to the Public Affairs Office no later than 90 days from the proposed event date. All tours and groups must complete this form and receive command approval before planning to visit Evans Army Community Hospital.

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Public Health

Memoranda

2019 Fort Carson Public Health Strategic Plan - 8 Mar 2019

Fort Carson Department of Public Health’s Strategic Plan for 2019 to 2021 will guide through the strategic directions and priorities over the next two years. This strategic plan was created over the course of several months (November 2018 through March 2019) during weekly working group, and several strategic planning committee, meetings.

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Fact Sheets

Public Health Alert - Coronavirus Disease 2019 (COVID-19) - 28 Feb 2020

The Centers for Disease Control and Prevention (CDC), the Military Health System, and the U.S. Army Public Health Center are closely monitoring an outbreak of respiratory illness caused by a novel (new) coronavirus.

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Information Papers

2019-2022 Fort Carson Community Health Improvement Plan - 18 Jun 2019

The Community Health Improvement Plan is a long-term, systematic effort to address public health concerns identified by the public health Community Health Assessment, the command’s CR2C (previously the Community Health Promotion Council (CHPC) and the Installation Prevention Team.

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2019 Fort Carson Community Health Assessment - 22 Apr 2019

The Community Health Assessment is a vital tool for determining community strengths and weaknesses and identifying process improvements.

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Pamphlets

Fort Carson Department of Public Health Services - 18 Jun 2019

A guide to the Fort Carson Department of Public Health and the services provided.

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Newsletters

FCPH June 2020 Newsletter - 1 Jun 2020

Latest FCPH June 2020 Newsletter, Vol 2, Issue 2

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FCPH October 2019 Newsletter - 1 Oct 2019

FCPH Newsletter, Vol 1, Issue 5, October 2019.

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Radiology

Forms

DD FORM 2870 - 1 Dec 2003

AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION

This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information.

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Release of Information

Forms

DD FORM 2870 - 1 Dec 2003

AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION

This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information.

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DA FORM 5018-R - 1 Nov 1981

ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION

This form is required to request the release of Substance Use Disorder Clinical Care (SUDCC) documentation.

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Fact Sheets

Release of Protected Health Information to Custodial and Noncustodial Parents and Stepparents - 2 Aug 2019

Use this table to determine if Custodial and Noncustodial Parents and Stepparents have access to a Minors' Medical records and Medical Appointments.

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US Army Medical Command (MEDCOM)

Information Papers

Army Medicine Campaign Plan - 1 Mar 2018

The Army Medicine Campaign Plan (AMCP) 2018 expresses the comprehensive organizational plan for United States Army Medical Command (USA MEDCOM) and the Office of The Surgeon General (OTSG) to fulfill the Army Medicine Vision through the alignment of Ends, Ways and Means within a year of execution. The process of developing this plan demanded a careful examination of Army Medicine, the needs of those it serves, its stakeholders and the environment.

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Army Medicine Vision - 3 Nov 2016

Army Medicine is the Nation’s premier expeditionary and globally integrated medical force ready to meet the ever-changing challenges of today and tomorrow.

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Women's Health

Forms

OB INTAKE - 1 Nov 2017

The OB Intake form is required prior to your first appointment during pregnancy.

Download

Fact Sheets

FAMILY CENTERED CARE - 15 Sep 2014

Learn about the Family Centered Care approach.

Download

NUTRITION FACTS - 15 Sep 2014

The Harvard School of Public Health nutrition guidlines during pregnancy.

Download

FETAL KICK COUNTS - 12 May 2011

Counting your baby’s movements is an excellent way of knowing that your baby is doing well. Get Fetal Kick Count information and a chart for recording your baby's movements.

Download

OB ULTRASOUNDS - 12 May 2011

Learn about OB Ultrasounds.

Download

PREFERRED PREGNANCY MEDICATIONS - 5 May 2011

Over the counter medicaion reccomendations while pregnant.

Download