Patient Documents and Forms Medical Clearances Home Frequently Asked Questions (FAQ) Patient Documents and Forms HomeMedical Clearances…Patient Documents and Forms hide Patient Documents and Forms Clearance Forms Visit the Medical Clearances page for information on how to use these forms. Available to download from this page: DS-1843: Medical History and Examination For Individuals Age 12 and Older DS-1622: Medical History and Examination For Children Age 11 and Younger DS-3057: Medical Clearance Update (MCU) Form DS-6570: ESCAPE Posts Pre-Deployment Physical Exam Acknowledgement Form Available from your HR representative: DS-3069: Authorization for Medical Examination (Note: This form must be signed by your agency’s hiring authority.) Available on OpenNet or by emailing MEDClearances@state.gov: MED ISO 3003: Health Unit Access and Provision of Limited Medical Services to Unpaid Short-term or Seasonal Interns MED ISO 3308: DOD Civilian and DOD Contractor ICASS Verification Letter MED ISO 3308.5: Institutional Contractor ICASS Verification Letter MED ISO G23002: Notice of Privacy Practices MED ISO F23005: Authorization for Release of Protected Health Information MED ISO F23006: MED Privacy Policy Acknowledgement of Receipt Patient Documents MED Code of Conduct MED Notice of Privacy Practices [165 KB] MED Patient Bill of Rights and Responsibilities
