The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is a critical document used by military personnel and their dependents to authorize the release of their medical records. This form ensures that sensitive health information is shared appropriately, allowing for better coordination of care. Understanding how to fill out this form is essential for maintaining your health records, so take the first step by clicking the button below to get started.
The DD 2870 form plays a crucial role for service members and their families in navigating the complexities of healthcare benefits. This form is essential for those seeking to authorize the release of medical information or designate a representative to act on their behalf. It streamlines the process of obtaining necessary medical care and ensures that individuals can access their healthcare rights efficiently. By filling out the DD 2870, service members can grant permission for healthcare providers to share vital information with designated individuals, facilitating smoother communication and care coordination. Additionally, the form is designed to protect privacy, ensuring that sensitive health information is shared only with authorized parties. Understanding the purpose and proper completion of the DD 2870 is vital for anyone involved in military healthcare, making it an important tool in managing health-related matters effectively.
Prescribed by: DoDM 6025.18
CUI (when filled in)
(Updated 20231219)
AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION
PRIVACY ACT STATEMENT
AUTHORITY: Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C. Chapter 55, Medical and Dental Care; DoD Manual (DoDM) 6025.18, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): DD Form 2870 collects patient data and a patient’s, or their parent’s or legal representative’s, authorization for a military treatment facility or dental treatment facility or DoD health plan to use or disclose an individual’s protected health information.
ROUTINE USE(S): To third parties or individuals as per your written authorization.
APPLICABLE SORN: EDHA 07, Military Health Information System (June 15, 2020; 85 FR 36190). https://dpcld.defense.gov/Portals/49/Documents/
Privacy/SORNs/DHA/EDHA-07.pdf
DISCLOSURE: Voluntary. If you choose not to provide your information, no penalty may be imposed and there will be a non-release of the protected health information. This form will not be used for authorization to disclose substance abuse information or treatment, if any, within your medical records nor will it be used to authorize the use or disclosure of psychotherapy notes, if any, within your medical records.
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)
BOTH
INPATIENT
OUTPATIENT
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, NOV 2023
Controlled by: DHA
Reset
PREVIOUS EDITION IS OBSOLETE.
CUI Category: PRVCY
Distribution/Dissemination Control: FEDCON
POC: [email protected]
Completing the DD 2870 form is an important step in the process you are undertaking. After filling out the form, you will need to submit it to the appropriate authority for processing. Ensure that all information is accurate and complete to avoid delays.
The DD 2870 form is a Department of Defense document used to authorize the release of medical information. It is primarily utilized by service members, veterans, and their dependents to allow healthcare providers to share medical records with specified parties. This form ensures that individuals can manage their health information effectively while maintaining privacy and compliance with regulations.
Any service member, veteran, or eligible dependent who wishes to grant permission for their medical records to be shared must complete the DD 2870 form. This includes those seeking treatment from civilian healthcare providers or those who need their records transferred between facilities. It is crucial for anyone who wants to ensure their medical information is accessible to authorized individuals.
Filling out the DD 2870 form involves several straightforward steps:
After completing the form, submit it to the appropriate healthcare provider or facility.
The validity of the DD 2870 form can vary based on the specific circumstances of the authorization. Generally, the authorization remains in effect until the purpose for which it was granted is fulfilled or until you revoke it in writing. It is wise to check with the receiving party for their policies regarding the duration of the authorization.
You can obtain the DD 2870 form from several sources:
Always ensure you are using the most current version of the form to avoid any issues with your request.
Incorrect Personal Information: Many individuals fail to provide accurate personal details such as their name, address, and Social Security number. This can lead to delays in processing.
Missing Signatures: It's common for people to overlook signing the form. Without a signature, the application cannot be processed, which can cause frustration.
Not Completing All Sections: Some users skip sections they think are unnecessary. Each part of the form is important, and leaving sections blank can result in rejection.
Providing Incomplete Documentation: Applicants often forget to include required documents. Ensure all necessary paperwork is attached to avoid delays.
Misunderstanding the Purpose: Some individuals fill out the form without fully understanding its purpose. It’s essential to know what the DD 2870 is used for to complete it correctly.
The DD 2870 form is a crucial document used primarily for the release of medical records and information related to military personnel. However, several other forms and documents often accompany it in various processes. Below is a list of these related documents, each serving a specific purpose.
Understanding these documents can help streamline processes related to military service and benefits. Each form plays a role in ensuring that service members and veterans receive the appropriate care and recognition they deserve.
The DD Form 2870 is a request for medical records and health information. It shares similarities with the HIPAA Authorization Form, which allows individuals to authorize the release of their medical records. Both forms require specific information about the patient and the healthcare provider. They ensure that individuals have control over who accesses their personal health information, promoting privacy and compliance with regulations. The key difference lies in the context; while the DD Form 2870 is specific to military medical records, the HIPAA form applies to all healthcare providers under federal law.
Another document similar to the DD Form 2870 is the Patient Authorization for Release of Information form. This form is often used in various healthcare settings to grant permission for the sharing of medical information. Like the DD Form 2870, it requires the patient’s details and specifies the information being requested. Both forms emphasize the importance of informed consent, ensuring that patients understand who will receive their information and for what purpose.
The Medical Records Release Form is also comparable to the DD Form 2870. This document is used by patients to request their medical records from healthcare providers. Both forms serve the same fundamental purpose: to facilitate the transfer of medical information while safeguarding patient privacy. They typically require similar identifying information and may have time constraints regarding how long the authorization is valid.
The Authorization for Use or Disclosure of Protected Health Information form is another document that aligns with the DD Form 2870. This form is utilized in various healthcare environments to allow for the sharing of health information. Both documents require detailed information about the patient and the recipient of the information. They also ensure that patients are aware of their rights regarding their health data, reinforcing the importance of consent in the healthcare process.
Additionally, the Release of Information form used in research studies shares characteristics with the DD Form 2870. This document is essential for obtaining permission from participants to use their health information for research purposes. Both forms prioritize the protection of personal health information and the necessity of informed consent. They outline the specific information being shared and the reasons for its use, ensuring transparency for the individuals involved.
Lastly, the Consent for Treatment form can be viewed as similar to the DD Form 2870. While primarily focused on granting permission for medical treatment, it often includes sections about the sharing of medical information with other providers. Both documents highlight the importance of patient autonomy and informed consent, allowing individuals to make decisions about their health care and the information that may be shared with others.
When filling out the DD 2870 form, it's important to follow certain guidelines to ensure that your application is processed smoothly. Below is a list of things to do and things to avoid.
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is often misunderstood. Here are nine common misconceptions about this form, along with clarifications to help you better understand its purpose and use.
This form is applicable to both active-duty and retired military members, as well as their dependents. Anyone who has a need for medical or dental information can use this form.
While it may not be required in every situation, if you want access to specific medical or dental records, completing this form is essential for authorization.
Although primarily associated with medical records, the DD 2870 can also be used to request dental information. It covers both types of records.
This form must be submitted to the appropriate military medical facility or dental office. Each branch of the military has specific guidelines for submission.
Generally, there is no fee for requesting medical or dental records using this form. However, some facilities may charge for copies of records, which is separate from the form itself.
The authorization provided by the DD 2870 does not expire unless specified by the individual. However, it is good practice to renew the authorization periodically if records are needed over an extended period.
Individuals have the right to revoke their authorization at any time. This can be done by submitting a written request to the facility where the form was submitted.
This form can be used for various purposes, not just emergencies. It is often used for routine requests for information, such as for ongoing treatment or legal matters.
While the form authorizes the release of information, it does not guarantee that all requested records will be provided. Access may depend on the nature of the records and privacy regulations.
Filling out the DD 2870 form is an important process for service members and their families seeking medical care and benefits. Here are some key takeaways to keep in mind:
Understanding these key points can help streamline your experience with the DD 2870 form, ensuring that you receive the necessary medical care without unnecessary delays.