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

___________________________________________________________________

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.

___________________________________________________________________

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.

___________________________________________________________________

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.

___________________________________________________________________

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.

___________________________________________________________________

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.

___________________________________________________________________

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.

___________________________________________________________________

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.

___________________________________________________________________

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:

      Ms. Brenda L. Romine, Panel Chair
      Ms. Debra A. Erickson, Member
      Mr. Christopher D. Carey, Member

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.




                                   BRENDA L. ROMINE
                                   Panel Chair