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DD 2870 Sample

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

 

 

 

 

Reset

 

 

 

 

 

 

 

 
⇓ PDF File

Instructions on Utilizing DD 2870

Filling out the DD 2870 form is an important step in accessing certain benefits. After completing the form, you will need to submit it to the appropriate office for processing. Ensure that all information is accurate to avoid delays.

  1. Begin by downloading the DD 2870 form from the official website or obtaining a physical copy from the appropriate office.
  2. Carefully read the instructions provided on the form to understand what information is required.
  3. In Section 1, enter your personal information, including your full name, Social Security number, and contact details.
  4. Proceed to Section 2 and indicate the type of benefits you are applying for. Be specific in your selection.
  5. In Section 3, provide any additional information requested, such as your military status or relationship to the service member.
  6. Review Section 4, which may require you to certify your information. Sign and date the form where indicated.
  7. Before submitting, double-check all entries for accuracy. Ensure that there are no omissions or errors.
  8. Submit the completed form to the designated office, either in person or via mail, according to the instructions provided.

Misconceptions

The DD 2870 form is an important document used by the Department of Defense. However, there are several misconceptions surrounding its purpose and use. Here are five common misconceptions:

  1. The DD 2870 is only for military personnel.

    This form is not exclusive to military members. It can also be used by eligible family members and dependents seeking benefits or services.

  2. Filling out the DD 2870 guarantees benefits.

    While the form is necessary to apply for certain benefits, submission does not guarantee approval. Eligibility criteria must still be met.

  3. The DD 2870 form is only required once.

    In some cases, individuals may need to submit the form multiple times, especially if their circumstances change or if they are applying for different benefits.

  4. All information on the DD 2870 is confidential.

    While personal information is protected, certain details may be shared with relevant agencies for processing claims or verifying eligibility.

  5. The DD 2870 can be submitted online only.

    This form can be submitted through various methods, including in-person at designated offices or via mail, depending on the specific requirements of the agency involved.

Documents used along the form

The DD 2870 form is an essential document used primarily for requesting access to military health records. However, it is often accompanied by other forms and documents that help streamline the process or provide additional information. Below is a list of some commonly used forms that may be relevant when dealing with the DD 2870.

  • DD Form 214: This form serves as a certificate of release or discharge from active duty. It provides essential information about a service member's military service and is often required for accessing certain benefits.
  • SF 180: The Standard Form 180 is used to request military records from the National Archives. It is particularly helpful for veterans seeking copies of their service records, which may be necessary for filling out the DD 2870.
  • VA Form 21-526EZ: This form is used to apply for veterans’ disability compensation. If a veteran is seeking medical records to support a disability claim, they may need to submit this form alongside the DD 2870.
  • DD Form 1172-2: This document is used for applying for military ID cards and benefits. It can be important for dependents of service members who may also need access to medical records.
  • HIPAA Authorization Form: This form allows healthcare providers to release medical information. When dealing with military health records, a HIPAA authorization may be necessary to ensure compliance with privacy regulations.
  • Washington Power of Attorney: This legal document allows individuals to appoint someone to manage their affairs when they are unable to make decisions themselves. To ensure your interests are protected, fill out the form by clicking the button below. All Washington Forms
  • DA Form 2823: This is a sworn statement form used to document personal accounts. In some cases, a statement may be required to support the request for records or to clarify the need for access.
  • SF 50: The Standard Form 50 is a notification of personnel action. It may be relevant for federal employees who are transitioning to veteran status and need to provide proof of employment history.

In conclusion, while the DD 2870 form is crucial for accessing military health records, these accompanying documents play significant roles in ensuring that requests are processed smoothly. Having the right forms on hand can make a substantial difference in the efficiency of obtaining necessary information.