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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

 

 

 

 

 

 

 

 

Document Information

Fact Name Description
Purpose The DD Form 2870 is used to authorize the release of medical information for military personnel and their dependents.
Who Uses It This form is primarily utilized by active duty service members, veterans, and their family members seeking access to medical records.
Submission Process Completed forms must be submitted to the appropriate medical facility or health care provider to process the request.
Information Required Individuals must provide personal details, including name, Social Security number, and the specific medical records requested.
Confidentiality All information provided is protected under the Health Insurance Portability and Accountability Act (HIPAA), ensuring privacy.
State-Specific Considerations Some states may have additional laws governing the release of medical records, such as California's Confidentiality of Medical Information Act.
Expiration The authorization typically remains valid for one year from the date it is signed unless otherwise specified.
Revocation Individuals have the right to revoke their authorization at any time, which must be done in writing.
Access to Records Upon approval, individuals can access their medical records, which may include treatment history and diagnostic information.

DD 2870 - Usage Guidelines

After obtaining the DD 2870 form, you will need to fill it out accurately to ensure that your request is processed without delays. Follow these steps carefully to complete the form.

  1. Start by entering your personal information in the designated fields. This includes your full name, address, and contact information.
  2. Provide your Social Security number or other identification numbers as required.
  3. Fill in the section that asks for your military status. Indicate whether you are active duty, retired, or a dependent.
  4. In the next section, specify the type of request you are making. Be clear and concise in your description.
  5. Sign and date the form at the bottom. Ensure your signature matches the name provided at the top.
  6. Review the completed form for any errors or missing information. Double-check all entries for accuracy.
  7. Once you are satisfied with the form, submit it according to the instructions provided. This may involve mailing it or submitting it electronically.

Following these steps will help ensure that your DD 2870 form is filled out correctly and submitted properly.

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Dos and Don'ts

When filling out the DD 2870 form, it is important to be meticulous and thorough. Here are some essential dos and don’ts to keep in mind:

  • Do read the instructions carefully before starting. Understanding the requirements will help you avoid mistakes.
  • Do provide accurate and complete information. Incomplete forms can lead to delays in processing.
  • Do double-check your entries for any errors. A second look can catch mistakes you might have missed initially.
  • Do sign and date the form where required. An unsigned form may be considered invalid.
  • Do keep a copy of the completed form for your records. This can be helpful for future reference.
  • Don't rush through the form. Taking your time can prevent errors and ensure accuracy.
  • Don't leave any required fields blank. Each section must be filled out as instructed.
  • Don't use white-out or other correction methods. If you make a mistake, it’s best to start over with a new form.
  • Don't forget to check the submission guidelines. Different offices may have specific requirements for submission.
  • Don't assume that someone else will check your work. It’s your responsibility to ensure everything is correct.

Common mistakes

The DD 2870 form, which is used for requesting a dependent's medical care, is an important document for military families. However, mistakes can often occur during the completion process. Here are six common errors to avoid:

  1. Incomplete Information: Many individuals fail to provide all required personal details. Missing a name, Social Security number, or date of birth can lead to delays in processing.

  2. Incorrect Signatures: It’s essential that the form is signed by the appropriate parties. Sometimes, individuals forget to sign, or they may have someone else sign on their behalf, which is not acceptable.

  3. Failure to Update Information: If there have been recent changes in family status, such as a divorce or the birth of a new child, these updates must be reflected on the form. Neglecting to do so can result in complications.

  4. Not Following Instructions: Each section of the DD 2870 form has specific guidelines. Some people overlook these instructions, leading to the submission of incomplete or incorrect information.

  5. Missing Supporting Documents: Certain attachments may be required to validate the request. Failing to include these documents can cause the application to be returned or denied.

  6. Submitting the Form to the Wrong Office: Understanding where to send the completed form is crucial. Sending it to the wrong department can significantly delay the processing time.

Being aware of these common mistakes can help ensure a smoother experience when filling out the DD 2870 form. Attention to detail and careful review of the document can prevent unnecessary complications.

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