The DD 2870 form is a request for a service member's medical records, crucial for veterans seeking benefits or care. Understanding how to complete this form can streamline the process of obtaining necessary documentation. Take action now to ensure your records are accessible by filling out the form below.
The DD 2870 form is an essential document for individuals seeking to access their military medical records and benefits. This form plays a crucial role in ensuring that service members and veterans receive the healthcare and support they deserve. It is primarily used to authorize the release of medical information, allowing healthcare providers to share pertinent details with authorized parties. By completing the DD 2870, individuals can streamline their access to necessary medical services, ensuring that their health needs are met efficiently. Additionally, the form serves as a protective measure, safeguarding personal health information while facilitating communication between various healthcare entities. Understanding the significance of the DD 2870 is vital for anyone navigating the military healthcare system, as it lays the groundwork for accessing vital services and support.
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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Coloum Graph - Column 4: Your opinion or reaction to this point.
The DD 2870 form is often misunderstood. Here are nine common misconceptions about it:
While the form is primarily used by military members, eligible dependents can also use it to request health care services.
For certain health care services, completing the DD 2870 is mandatory to access benefits.
There are specific time frames for submission, especially when seeking benefits related to a particular incident or service.
Retired service members and their families can also use the form for health care requests.
Many find it straightforward, with clear sections that guide users through the necessary information.
Applicants can request corrections or updates if needed, as long as they follow the proper procedures.
Submitting the form does not automatically ensure that services will be approved; eligibility is still evaluated.
The form can be used for a range of health care services, including preventive and urgent care.
The DD 2870 can also be obtained in physical form at military installations and health care facilities.
The DD 2870 form, known as the "Authorization for Disclosure of Medical or Dental Information," is an essential document used by military personnel and their families to allow the release of medical or dental records. When completing this form, there are several other documents that may also be required to ensure a smooth process. Below is a list of commonly associated forms and documents that often accompany the DD 2870.
Understanding the various documents that accompany the DD 2870 form is crucial for ensuring that the process of obtaining medical or dental information is efficient and compliant with regulations. Each of these forms plays a unique role in supporting service members and their families as they navigate the complexities of military healthcare and benefits.