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DD 2870 Preview
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
AUTHORITY: Public Law
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
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) |
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2. DATE OF BIRTH (YYYYMMDD) |
3. SOCIAL SECURITY NUMBER |
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4. PERIOD OF TREATMENT: FROM - TO (YYYYMMDD) |
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5. TYPE OF TREATMENT (X one) |
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OUTPATIENT |
INPATIENT |
BOTH |
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SECTION II - |
DISCLOSURE |
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6. I AUTHORIZE |
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TO RELEASE MY PATIENT INFORMATION TO: |
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(Name of Facility/TRICARE Health Plan) |
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a. NAME OF PERSON OR ORGANIZATION TO RECEIVE MY |
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b. ADDRESS (Street, City, State and ZIP Code) |
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MEDICAL INFORMATION |
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c. TELEPHONE (Include Area Code) |
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d. FAX (Include Area Code) |
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7. REASON FOR REQUEST/USE OF MEDICAL INFORMATION (X as applicable) |
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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) |
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(If applicable) |
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SECTION IV - FOR STAFF USE ONLY (To be |
completed only upon receipt of written revocation) |
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14. X IF APPLICABLE:
AUTHORIZATION REVOKED
15. REVOCATION COMPLETED BY
16.DATE (YYYYMMDD)
17. IMPRINT OF PATIENT IDENTIFICATION PLATE WHEN AVAILABLE |
SPONSOR NAME: |
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SPONSOR RANK: |
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FMP/SPONSOR SSN: |
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BRANCH OF SERVICE: |
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PHONE NUMBER: |
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DD FORM 2870, DEC 2003 |
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Documents used along the form
The DD 2870 form is a key document used in the military context, particularly for the purpose of authorizing the release of medical records and information. However, it is often accompanied by other forms and documents that serve various functions in the military and healthcare systems. Below is a list of commonly used forms that may be needed alongside 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, including dates of service and type of discharge.
- SF 180: The Standard Form 180 is used to request military records. This form is crucial for veterans seeking access to their service records, including medical and personnel files.
- DD Form 149: This form is used to apply for a correction of military records. It allows individuals to request changes to their discharge status or other records that may contain errors.
- VA Form 21-526EZ: This is the application for disability compensation and related compensation benefits. Veterans use this form to initiate claims for benefits based on service-related disabilities.
- DD Form 2875: This form is used to request access to the Defense Health Agency’s (DHA) systems. It is essential for personnel who need to access sensitive health information.
- VA Form 21-534EZ: This form is used to apply for Dependency and Indemnity Compensation (DIC) benefits. It is typically submitted by surviving spouses or dependents of veterans who have passed away.
- DD Form 1300: This is the Report of Casualty form. It is used to report the death of a service member and includes information necessary for benefits processing.
- Durable Power of Attorney: It is vital for appointing a representative to manage financial matters on behalf of an individual, even in cases of incapacity. More details can be found in the Durable Power of Attorney form.
- SF 600: The Chronological Record of Medical Care is a form that documents a patient’s medical treatment and health history within military healthcare facilities.
- DD Form 2870-1: This form is a supplement to the DD 2870, used specifically for authorizing the release of mental health records, which are subject to additional privacy protections.
Understanding these forms can help individuals navigate the complex landscape of military and veteran benefits. Each document plays a significant role in ensuring that service members and veterans receive the care and recognition they deserve.
Similar forms
- SF 180: This is a request for military records. Like the DD 2870, it allows individuals to access their service records, ensuring transparency and accountability in record-keeping.
- New York Trailer Bill of Sale: This legal document is vital for proving the sale and transfer of ownership for a trailer, ensuring that both buyers and sellers understand their obligations as stated in nypdfforms.com/trailer-bill-of-sale-form/.
- VA Form 21-526EZ: This is used to apply for veterans' disability compensation. Similar to the DD 2870, it requires personal information and details about military service to process claims.
- DD Form 214: This document summarizes a service member's military career. It is similar to the DD 2870 in that both are essential for verifying military service and benefits eligibility.
- SF 15: This form is used for veteran preference in federal hiring. It parallels the DD 2870 by requiring documentation of military service to qualify for certain benefits and opportunities.
- VA Form 21-4142: This is a release form for medical records. Much like the DD 2870, it facilitates access to necessary information for processing claims and ensuring veterans receive appropriate care.
Misconceptions
The DD 2870 form is often misunderstood. Here are four common misconceptions about it, along with clarifications.
- The DD 2870 form is only for military personnel. This is incorrect. The form is used by both military members and their eligible dependents. It serves to authorize the release of medical information.
- Filling out the DD 2870 form is optional. This is a misconception. For certain medical services and benefits, submitting the form is a requirement. It ensures that the necessary medical information is shared appropriately.
- The information provided on the DD 2870 form is not protected. This is false. The form is designed to comply with privacy regulations. The information shared is safeguarded to protect the individual’s confidentiality.
- The DD 2870 form is only needed once. This is misleading. Depending on the situation, you may need to submit the form multiple times. Each instance of care or service may require a new authorization.
Understanding these points can help ensure that individuals navigate the process more effectively and protect their rights regarding medical information.
Understanding DD 2870
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What is the DD 2870 form?
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is a document used by the Department of Defense. It allows military personnel and their beneficiaries to authorize the release of their medical or dental records to designated individuals or entities. This form is essential for ensuring that sensitive health information is shared appropriately and with the consent of the individual concerned.
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Who needs to fill out the DD 2870 form?
Any active duty service member, veteran, or eligible family member who wishes to authorize the release of their medical or dental information must complete the DD 2870 form. This includes situations where a patient wants to share their health records with a healthcare provider, insurance company, or other third parties.
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How do I obtain the DD 2870 form?
The DD 2870 form can be obtained from various sources. It is available online through the official Department of Defense website. Additionally, military medical facilities often have copies available at their administrative offices. It is advisable to ensure you have the most current version of the form.
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What information is required on the DD 2870 form?
When filling out the DD 2870 form, individuals must provide specific information, including:
- The name and contact details of the person authorizing the release.
- The name of the individual or organization receiving the information.
- A description of the information to be disclosed.
- The purpose of the disclosure.
- The date the authorization is signed.
It is crucial to complete all sections accurately to avoid delays in processing.
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How long is the DD 2870 form valid?
The authorization provided by the DD 2870 form is generally valid for one year from the date it is signed. However, individuals can specify a shorter duration if desired. It is important to keep track of the expiration date and renew the authorization if ongoing access to medical or dental records is needed.
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Can I revoke the authorization once I submit the DD 2870 form?
Yes, individuals have the right to revoke their authorization at any time. To do this, a written notice must be provided to the entity that received the authorization. It is advisable to keep a copy of the revocation for personal records. Once revoked, the entity must cease any further disclosures of the individual’s medical or dental information.