The DD Form 2870, also known as the "Authorization for Disclosure of Medical or Dental Information," is a crucial document used by military personnel and their families. It facilitates the release of medical and dental records, ensuring that vital information is available for necessary evaluations and treatment. If you need assistance with this form, click the button below to get started.
The DD Form 2870 plays a vital role in the realm of military healthcare, serving as a key document for individuals seeking access to their medical records. This form is designed not only to facilitate the request for medical information but also to ensure that the rights of service members and their families are protected. By providing essential details such as the patient's full name, identification number, and the specific medical records being requested, the DD 2870 streamlines the process of obtaining medical documentation. It is important to note that this form is crucial for maintaining continuity of care, especially when service members transition to civilian life or need comprehensive health assessments. Understanding the significance of this form, alongside the process involved in completing and submitting it, can empower individuals to take charge of their healthcare needs efficiently and effectively. In a world where timely access to medical information can impact treatment outcomes, familiarity with the DD 2870 is immensely beneficial.
Prescribed by: DoDM 6025.18
CONTROLLED when filled
AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION
PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974 (Public Law 93-579), the notice informs you of the purpose of the form and howit will be used. Please read it carefully.
AUTHORITY: Public Law 104-191; E.O. 9397 (SSAN); DoD 6025.18-R.
PRINCIPAL PURPOSE(S): This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information.
ROUTINE USE(S): To any third party or the individual upon authorization for the disclosure from the individual for: personal use; insurance; continued medical care; school; legal; retirement/separation; or other reasons.
DISCLOSURE: Voluntary. Failure to sign the authorization form will result in the non-release of the protected health information.
This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an alcohol or drug abuse treatment program. In addition, any use as an authorization to use or disclose psychotherapy notes may not be combined with another authorization except one to use or disclose psychotherapy notes.
SECTION I - PATIENT DATA
1. NAME (Last, First, Middle Initial)
2. DATE OF BIRTH (YYYYMMDD)
3. SOCIAL SECURITY NUMBER
4. PERIOD OF TREATMENT: FROM - TO (YYYYMMDD)
5. TYPE OF TREATMENT (X one)
OUTPATIENT
INPATIENT
BOTH
SECTION II -
DISCLOSURE
6. I AUTHORIZE
TO RELEASE MY PATIENT INFORMATION TO:
(Name of Facility/TRICARE Health Plan)
a. NAME OF PERSON OR ORGANIZATION TO RECEIVE MY
b. ADDRESS (Street, City, State and ZIP Code)
MEDICAL INFORMATION
c. TELEPHONE (Include Area Code)
d. FAX (Include Area Code)
7. REASON FOR REQUEST/USE OF MEDICAL INFORMATION (X as applicable)
PERSONAL USE
INSURANCE
CONTINUED MEDICAL CARE
RETIREMENT/SEPARATION
SCHOOL
LEGAL
OTHER (Specify)
8. INFORMATION TO BE RELEASED
9. AUTHORIZATION START DATE (YYYYMMDD)
10. AUTHORIZATION EXPIRATION
DATE (YYYYMMDD)
SECTION III - RELEASE AUTHORIZATION
ACTION COMPLETED
I understand that:
a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my medical records are kept or to the TMA Privacy Officer if this is an authorization for information possessed by the
TRICARE Health Plan rather than an MTF or DTF. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or disclosed my protected information on the basis of this authorization.
b. If I authorize my protected health information to be disclosed to someone who is not required to comply with federal privacy protection regulations, then such information may be re- disclosed and would no longer be protected.
c. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance with the requirements of the federal privacy protection regulations found in the Privacy Act and 45 CFR 164.524.ss
d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to
obtain this authorization.
I request and authorize the named provider/treatment facility/TRICARE Health Plan to release the information described above to the named individual/organization indicated.
11. SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE
12. RELATIONSHIP TO PATIENT
13. DATE (YYYYMMDD)
(If applicable)
SECTION IV - FOR STAFF USE ONLY (To be
completed only upon receipt of written revocation)
14. X IF APPLICABLE:
AUTHORIZATION REVOKED
15. REVOCATION COMPLETED BY
16.DATE (YYYYMMDD)
17. IMPRINT OF PATIENT IDENTIFICATION PLATE WHEN AVAILABLE
SPONSOR NAME:
SPONSOR RANK:
FMP/SPONSOR SSN:
BRANCH OF SERVICE:
PHONE NUMBER:
DD FORM 2870, DEC 2003
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Completing the DD 2870 form is an important step in the process you are undertaking. Follow these steps carefully to ensure your form is filled out correctly and submitted properly.
After submitting the DD 2870 form, your request will be processed. Keep an eye on any communications from the relevant office regarding the next steps or if they require further information.
What is the DD 2870 form?
The DD 2870 form is used to authorize the release of medical information for beneficiaries. This includes active duty service members, retirees, and their dependents. Completing this form ensures that medical professionals can share necessary healthcare details with the relevant parties, helping to streamline treatment and coordination of care.
Who needs to complete the DD 2870 form?
Any individual seeking to grant permission for their medical information to be shared must complete the DD 2870. This form may be required for service members or their dependents when they want to authorize another person or entity to access their medical records.
Where can I obtain the DD 2870 form?
You can download the DD 2870 form from the official Department of Defense Forms website. Additionally, medical facilities associated with the military may have physical copies available. It’s essential to ensure you have the most current version of the form.
How do I fill out the DD 2870 form?
To fill out the DD 2870 form, start by providing your personal information, including your name, service number, and contact details. Next, specify the records you are authorizing to be released and to whom. Carefully read the instructions provided on the form to ensure accurate completion. Finally, sign and date the form, indicating your permission for the release of the specified medical information.
Is there a deadline for submitting the DD 2870 form?
While there may not be a strict deadline for submitting the DD 2870 form, it is advisable to submit it as soon as possible. Prompt submission ensures that healthcare providers can access the necessary medical information without unnecessary delays, which is crucial for effective care.
What happens after I submit the DD 2870 form?
Once you submit the DD 2870 form, the authorized individual or organization will be granted access to your medical records as specified. Expect communication from the healthcare provider if further action or verification is needed. It’s important to keep a copy of the completed form for your records.
Can I revoke the authorization given in the DD 2870 form?
Yes, you can revoke your authorization at any time. To do this, you must submit a written notice to the entity that received your medical information. Include your details and specify that you wish to revoke the authorization. It’s advisable to confirm with the healthcare provider that this revocation has been processed to ensure your medical information is no longer shared.
Filling out the DD 2870 form can seem straightforward, but it’s easy to make mistakes. One common error is not including all required personal information. This form requires basic identification details such as name, Social Security number, and contact information. Missing this data can delay processing.
Another frequent mistake is failing to provide a clear and complete purpose for the request. It's essential to specify why you're submitting the form. If the purpose is vague or incomplete, it might lead to confusion and possible rejection of your form.
Some individuals neglect to include all necessary supporting documents. Each request may require additional paperwork, such as medical records or proof of service. Not attaching these documents can result in a hold on processing, causing frustration and delays.
Furthermore, many people forget to sign and date the form. This omission can be easily overlooked but is crucial. Without a signature, the form may be considered incomplete, and it won't be processed.
Writing legibly is another important consideration. Illegible handwriting can lead to misunderstandings or errors in processing. Using clear, printed letters helps ensure that your information is read correctly.
Another mistake involves not keeping a copy of the submitted form. Keeping a personal record comes in handy if you need to refer back to the submission or if an issue arises later.
Some individuals fill out parts of the form incorrectly, such as selecting the wrong type of request. Make sure to double-check that you've chosen the appropriate option that corresponds to your needs.
Additionally, people sometimes underestimate the timelines involved. After submitting the form, processing can take time. Failing to plan for this delay can lead to unnecessary stress.
Lastly, it’s crucial to verify that your contact information is current. If the information changes after you've submitted the form, you might miss important updates or requests for more information.
Avoiding these common mistakes can make the process smoother and more efficient. Careful attention to detail will help ensure that your DD 2870 form is processed without delay.
The DD 2870 form is often utilized within the military and veteran healthcare systems to request access to medical records and other health-related information. Along with this form, several other documents and forms are typically required or recommended. These documents facilitate the process of obtaining necessary health records and ensure compliance with relevant regulations.
In conclusion, these forms and documents work in concert with the DD 2870, supporting veterans and service members in accessing their healthcare information and ensuring they receive the benefits and services they deserve.
The DD 2870 form is commonly used within the Department of Defense for obtaining authorization and consent for the release of health information. While the DD 2870 has its specific purpose, it bears similarities to several other documents related to health information release and privacy rights. Here are six such documents:
These forms, while distinct in use and context, share a common goal of protecting an individual’s privacy while allowing necessary information sharing under specific terms.
When filling out the DD 2870 form, it is essential to follow specific guidelines to ensure accuracy and completeness. Below are some important do's and don'ts to consider.
By adhering to these guidelines, you can help ensure that your application is processed smoothly and efficiently.
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is often misunderstood. Here are six common misconceptions surrounding this form, along with clarifications to help set the record straight.
This form can be utilized by not only military personnel but also their dependents and certain eligible family members. It applies to anyone seeking to authorize the release of medical or dental records.
While you may not be required to fill out the form for every medical visit, it is essential when you need specific health records disclosed. Employers or other facilities may require this authorization to release information.
An oral request will generally not suffice. The form must be completed and submitted in writing to ensure proper documentation of the authorization.
In fact, the form does include an expiration date for the authorization, which helps protect your privacy. This ensures that the information does not remain accessible indefinitely.
Individuals can revoke their authorization at any time. To do so, a written notice should be provided to the entity that received the original authorization.
The form can also be used for dental records. It is a versatile document that covers both medical and dental information.
Understanding these misconceptions can help you effectively navigate the use of the DD 2870 form when necessary.
Filling out and using the DD 2870 form is an important task that requires attention to detail. Here are some key takeaways to keep in mind:
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