A gold color metal and enamel device 1 3/16 inches (3.02 cm) in height overall consisting of a maroon Greek cross with horizontal center upon the upper edge of a white stylized waterfall, the cross issuing gold rays from center and enclosed by a green annulet terminating at either side of the waterfall and inscribed with the words "SUPPORT THE STRENGTH" in gold letters.
Maroon and white are the colors for the Army Medical Department. The cross and rays symbolize the Hospital's function of providing medical care, and the annulet, with rays for spokes, suggest part of a wheel in reference to the unit's former mission as an Evacuation Hospital. The color green denotes health and life, and the waterfall indicates the unit's location in Niagara Falls, New York.
The distinctive unit insignia was originally approved for the 365th Evacuation Hospital on 6 June 1972. It was redesignated for the 865th General Hospital effective 17 September 1999. The insignia was redesignated effective 16 June 1997 for the 865th Combat Support Hospital.