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AF | BCMR | CY2010 | BC-2010-00209
Original file (BC-2010-00209.doc) Auto-classification: Denied

                            RECORD OF PROCEEDINGS
             AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS

IN THE MATTER OF:      DOCKET NUMBER:  BC-2010-00209
            INDEX CODE:  134.02
            COUNSEL:  NONE

            HEARING DESIRED:  NO

_________________________________________________________________

APPLICANT REQUESTS THAT:

The Standard Form 600, Chronological Record of Medical Care form,  dated  24
Feb 09, and other medical documentation mentioning  “OPIOID  DEPENDENCY”  be
removed from his records.

_________________________________________________________________

APPLICANT CONTENDS THAT:

During his second  week  of  basic  training,  he  made  a  false  statement
regarding his use of drugs.  He was scared, depressed and  experienced  many
emotions; therefore, he  believed  his  statement  would  allow  him  to  be
discharged.  He told his sergeant that he spent time in a drug rehab  center
and was instructed to report to Behavioral Assessment Services (BAS)  for  a
mental evaluation.  He lied when asked about the drugs he had used  and  his
length of time spent in the drug rehab.  The physician  knew  he  was  lying
and counseled him.  He was punished for lying but was  not  discharged  from
service.  He was also removed from combat control school.

He is very sorry for the false  statement  he  made  regarding  his  use  of
drugs.  His actions were cowardly and based on emotions.  He has learned  to
love the Air Force.  His  medical  records;  however,  still  contain  false
“OPIOID DEPENDENCY” statements which he would like removed.

In support of his request, the applicant submits copies of medical reports.

The applicant's complete submission, with attachments, is at Exhibit A.

_________________________________________________________________

STATEMENT OF FACTS:

Information extracted from  the  Military  Personnel  Data  System  (MilPDS)
indicates  the  applicant  is  currently  assigned  duties  as   a   Vehicle
Operations Apprentice in the grade of  senior  airman  having  assumed  that
grade effective and with a date of rank of 6 Nov 09.

The remaining relevant facts pertaining to this application, extracted  from
the applicant’s military records, are contained in the  letter  prepared  by
the appropriate office of the Air Force at Exhibit B.

_________________________________________________________________

AIR FORCE EVALUATION:

AFMOA/SGAT cannot recommend denial or  grant  of  the  applicant’s  request.
However, SGAT recommends requesting  authorization  from  the  applicant  to
access the Pharmacy Data Transaction Service data base and  the  urine  drug
test data base to determine if there is any data  to  support  the  repeated
use of Opioids.

SGAT notes the medical documentation  provided  by  the  applicant  exhibits
several encounters  where  the  providers  annotated  either  a  history  of
withdrawal from pain medication,  a  history  of  an  addiction  to  Tylenol
w/Codeine, or a history of opioid dependency in remission.   However,  there
was  no  documentation  found  where  a  provider  actually  diagnosed   the
applicant with opioid dependency.  Additionally, the  diagnosis  of  ‘Opioid
Dependency, in Remission” was repeatedly noted throughout subsequent  visits
from Jul 07 through Oct 09 as an “AutoCite” feature found in the  Department
of Defense electronic medical  records  without  substantiating  history  to
support this diagnosis.  SGAT states encounters  after  2  Oct  09  did  not
include this diagnosis in the “AutoCite” section.

The complete SGAT evaluation is at Exhibit B.

_________________________________________________________________

APPLICANT'S REVIEW OF AIR FORCE EVALUATION:

A copy of the Air Force evaluation was forwarded to the applicant on 27  Aug
10, for review and comment within 30 days.  As of  this  date,  this  office
has received no response (Exhibit C).

_________________________________________________________________

THE BOARD CONCLUDES THAT:

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

2.  The application was timely filed.

3.  Insufficient relevant evidence has been  presented  to  demonstrate  the
existence of error or  injustice.   The  applicant’s  contentions  are  duly
noted; however, existing laws and/or regulations indicate he may obtain  the
relief he seeks by requesting his Primary  Care  Manager  (PCM)  remove  the
references to Opiods from his medical records.  The recommendation  provided
by the Air Force office of primary responsibility is  duly  noted;  however,
we find the applicant has not exhausted all of his administrative  remedies.
 Therefore, in view of the aforementioned, we find no basis  upon  which  to
recommend granting the relief sought in this case.

_______________________________________________________________

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  BC-2010-00209  in
Executive Session on 28 Oct 10, under the provisions of AFI 36-2603:

      , Panel Chair
      , Member
      , Member

The following documentary evidence was considered:

    Exhibit A.  DD Form 149, dated 13 Jan 10, w/atchs.
    Exhibit B.  Letter, AFMOA/SGAT, dated 20 Aug 10.
    Exhibit C.  Letter, SAF/MRBR, dated 27 Aug 10.




                                   Panel Chair

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