The DD 2870 form is a document used by military personnel to authorize the release of their medical records. This form ensures that service members can access their medical history when needed. Understanding its purpose and proper usage is crucial for maintaining health records efficiently.
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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The DD Form 2870, also known as the Authorization for Disclosure of Medical or Dental Information, is a crucial document used within the military and veteran community. However, several misconceptions surround this form that can lead to confusion. Here are nine common misunderstandings:
This form is not limited to active-duty members. Veterans and retired service members can also use it to authorize the release of their medical or dental records.
While healthcare providers often assist in the process, any individual can complete the form to request their own records or authorize someone else to do so.
The DD 2870 can be used multiple times. Whenever a new request for medical or dental information arises, a new form should be completed.
Completing the form does not ensure instant access. The timeframe for receiving records can vary based on the provider's policies and workload.
In addition to medical records, the DD 2870 can also be used for dental records. It covers all types of health-related information.
A notary public is not necessary for this form. Signing the form is sufficient, as long as it is completed by the authorized individual.
The form can be used for any healthcare provider that maintains records, including private practices, hospitals, and military treatment facilities.
Typically, there is no fee associated with completing the DD 2870 itself. However, some providers may charge for the copies of records.
Individuals can revoke their authorization at any time. It is important to communicate this revocation to the healthcare provider in writing.
Understanding these misconceptions can help individuals navigate the process more effectively and ensure they receive the necessary medical or dental information when needed.
Filling out the DD 2870 form can seem daunting, but it is essential for ensuring you receive the necessary benefits. Here are some key takeaways to help you navigate the process smoothly:
By keeping these takeaways in mind, you can ensure a smoother experience when filling out and using the DD 2870 form.
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