Form H4701, HHSC Out Card

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Effective Date
H4701.doc (121.5 KB)
H4701.pdf (12.33 KB)


Updated: 7/1984


To serve as a notification and documentation that a case record has been removed from a file, by whom, and the date.


When to Prepare Authorized staff prepare Form H4701 for each case at the time of certification, case opening, or on an as-reviewed basis. Form H4701 is placed in every open and closed case record.

No case record may be removed from a file without Form H4701 being filled out.

Detailed Instructions

The staff person removing the case record enters his name, organizational unit number, and the date charged out. He places the completed Form H4701 upright in the file in place of the case record. When he returns the case record, he enters the date returned, marks out his name, and replaces Form H4701 in the case record.