RECORD OF PROCEEDINGS
         AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS

IN THE MATTER OF:	DOCKET NUMBER:  BC-2003-01687
		INDEX CODE:  100.00

		COUNSEL:  NONE

		HEARING DESIRED: NO

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APPLICANT REQUESTS THAT:

All Standard Forms (SF) 600, Chronological Record of Medical Treatment, which do not contain any patient identification be removed from her record.

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APPLICANT CONTENDS THAT:

The unidentifiable documents led to an erroneous diagnosis when she was in the Air Force and with the Department of Veterans Affairs’ (DVA) denial of her claims for service-connected medical conditions reflected in her records.

In support of her appeal, applicant submitted a personal statement; excerpts from AFP 36-2607, dated 3 Nov 94; copies of SF Forms 600 (without identifiable data); and documents associated with her DVA claims. 

Applicant’s complete submission is at Exhibit A.

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STATEMENT OF FACTS:

On 5 Sep 69, applicant enlisted in the Regular Air Force for a period of four years in the grade of airman basic (AB/E-1).  She was promoted to the grade of sergeant (E-4) with an effective date and date of rank of 1 Jul 71.

Medical statements in the record reflect applicant was evaluated in Dec 70, and diagnosed with emotional instability, chronic, moderate, manifested by anxiety, depression, feelings of wanting to explode, crying spells, and sleep difficulty.  Stress was described as minimal, routine military duty.  Predisposition was described as a life long pattern.  Impairment was described as marked for military, mild for civil, social, and industrial adaptation.  Line of Duty Determination (LOD) was stated as No, condition existed prior to service (EPTS).  Separation was recommended at that time.  Subsequent to that evaluation, she had muscle spasms and tension in her back requiring Valium and Darvon compound.  
On 6 Nov 71, applicant was admitted to the hospital following an overdose of Valium and Darvon.  This was precipitated by rejection by family and friends.  She was diagnosed with emotional instability, chronic, moderate; a condition considered a predisposition for the depressive reaction.  She continued to manifest a tremendous amount of difficulty in adjusting to military life and separation was recommended as soon as possible.

Based on a previous examination, on 8 Mar 72, the hospital concluded applicant’s adjustment disorder rendered her unsuitable rather than unfit because of physical disability and recommended disposition through appropriate administrative means.

On 27 Mar 72, the squadron commander initiated administrative discharge action against the applicant for unsuitability due to an adjustment disorder, namely, emotional instability.  After consulting with military counsel, applicant waived her right to appear before an administrative discharge board and to submit statements in her own behalf.  On 31 Mar 72, the wing staff judge advocate found the case legally sufficient and recommended an honorable discharge.  On 10 Apr 72, the discharge authority approved the separation in accordance with AFM 39-12, section A, chap 2, para 2-4b, and directed applicant be discharged and furnished an honorable discharge certificate.

On 11 Apr 72, the applicant was honorably discharged under the provisions of AFM 39-12, with service characterized as honorable.  She served 2 years, 7 months, and 7 days on active duty.

On 27 Jan 83, the AFBCMR considered and denied applicant’s request that the diagnosis in her medical records be changed from “Depressive - Personality Disorder” to “Pre-Menstrual Stress Disorder with Depression.”

On 9 Jan 85, the Board reconsidered applicant’s amended request that the diagnosis “Personality Disorder” be changed to “”Premenstrual Tension/Premenstrual Syndrome with Adjustment Disorder with Emotional Features.”  The Board found insufficient evidence to approve the applicant’s stated request; nevertheless, they agreed with the Air Force evaluation and recommended the applicant’s reason for separation be changed to “Adjustment Disorder.”

On 15 May 90, the Board considered and denied applicant’s request that the diagnosis of an “Adjustment Disorder” as well as references to “emotional instability” be removed from her records.

On 30 Jan 98, the Board considered and denied applicant’s request that all documents in her master personnel records and health records, which did not bear her name or other identifying data, be removed from her records.

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AIR FORCE EVALUATION:

HQ AFMOA/SGZZ reviewed this application and recommended denial.  According to AFR 168-4, Administration of Medical Activities, 18 Jan 87 (earliest available edition), Chapter 12, para 12-42a, “Each form and document to be filed in the record contains a minimum identification of patient’s name, family member prefix, and SSAN under which the record is to be filed.”  The SF 600 is a two-sided form and, although patient identification information should be annotated on the front, there is no requirement for the reverse to contain that information.  They noted that three of the SF 600’s identified as lacking identifying data are, in fact, the reverse sides of forms which do contain the patient’s name, accounting for 10 out of the 20 referenced dates which do, in fact, have patient identifying data on the SF 600’s.

There is no redundant system or requirement in the Air Force to create and retain copies of retired medical records.  Thus, the Air Force no longer has any files in their possession to either confirm or refute the applicant’s contention that her medical records contains documents not belonging to her.  These records have not been in the possession of the Air Force system since approximately 1974.  Therefore, there is no way to determine what documents the original record contained.

A complete copy of the evaluation is at Exhibit C.

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APPLICANT'S REVIEW OF AIR FORCE EVALUATION:

Applicant disagreed with the comments and recommendation of the Air Force evaluation and provided additional documentation to refute the statements by the Air Force.  

Applicant’s complete response, with attachments, is at Exhibit E.  

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THE BOARD CONCLUDES THAT:

1.  The applicant has exhausted all remedies provided by existing law or regulations.

2.  The application was not timely filed; however, it is in the interest of justice to excuse the failure to timely file.

3.  Insufficient relevant evidence has been presented to demonstrate the existence of error or injustice.  We took notice of the applicant's complete submission in judging the merits of the case; however, we agree with the opinion and recommendation of the Air Force office of primary responsibility and adopt their rationale as the basis for our conclusion that the applicant has not been the victim of an error or injustice.  Therefore, in the absence of evidence to the contrary, we find no compelling basis to recommend granting the relief sought in this application.

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THE BOARD DETERMINES THAT:

The applicant be notified that the evidence presented did not demonstrate the existence of material error or injustice; that the application was denied without a personal appearance; and that the application will only be reconsidered upon the submission of newly discovered relevant evidence not considered with this application.

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The following members of the Board considered AFBCMR Docket Number BC-2003-01687 in Executive Session on 10 June 2004, under the provisions of AFI 36-2603:

The following documentary evidence was considered:

    Exhibit A.  DD Form 149, dated 1 May 03, w/atchs. 
    Exhibit B.  Applicant's Master Personnel Records.
    Exhibit C.  Letter, AFMOA/SGZZ, dated 9 Jul 03.
    Exhibit D.  Letter, SAF/MRBR, dated 18 Jul 03.
    Exhibit E.  Letter, Applicant, dated 23 Jul 03, w/atchs.

                                   Panel Chair