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The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," plays a crucial role in the management of medical records within the military healthcare system. This form is essential for service members and their dependents, as it authorizes the release of sensitive medical or dental information to designated individuals or organizations. By ensuring that personal health information is shared appropriately, the DD 2870 facilitates continuity of care and supports informed decision-making among healthcare providers. The form requires specific details, including the individual's information, the purpose of the disclosure, and the names of the authorized recipients. Additionally, it includes provisions for revoking the authorization, thus granting individuals control over their medical information. Understanding the significance and proper use of the DD 2870 is vital for maintaining privacy and ensuring compliance with healthcare regulations within military contexts.
Document Data
| Fact Name | Details |
|---|---|
| Purpose | The DD 2870 form is used to authorize the release of medical information. |
| Who Uses It | This form is commonly used by military personnel and veterans. |
| Submission | The completed form must be submitted to the appropriate medical facility. |
| Privacy Regulations | It complies with HIPAA regulations to protect patient information. |
| Validity Period | The authorization remains valid for one year unless revoked earlier. |
| State-Specific Forms | Some states may have additional forms governed by local laws. |
| Signature Requirement | A signature from the patient or legal representative is required. |
| Contact Information | It’s important to provide accurate contact details for follow-up. |
How to Write DD 2870
Filling out the DD 2870 form is an important step in the process you are undertaking. Once you have completed the form, it will need to be submitted according to the instructions provided by the relevant authority. Below are the steps to guide you through the completion of the form.
- Begin by gathering all necessary personal information, including your full name, Social Security number, and contact details.
- Read the instructions on the form carefully to understand what is required in each section.
- In the first section, enter your personal information accurately. Ensure that spelling and numbers are correct.
- Proceed to the next section, where you will provide details regarding your eligibility and the purpose of the request.
- Fill out any additional sections as required, paying attention to any specific questions or prompts.
- Review the completed form for any errors or omissions. Double-check all entries to ensure accuracy.
- Once you are satisfied with the information provided, sign and date the form where indicated.
- Finally, follow the submission guidelines to send the form to the appropriate office or individual.
DD 2870 Example
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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