The DD 2870 form is a document used by the Department of Defense to authorize the release of medical information. This form is essential for service members and veterans seeking to share their health records with medical providers. Understanding its purpose and how to complete it can help streamline the process of accessing necessary care.
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 within the military and veteran communities. It allows service members and veterans to authorize the release of their medical or dental information to specific individuals or organizations. This form ensures that your personal health information is shared only with those you trust and for purposes you agree to.
Who needs to fill out the DD 2870 form?
Any service member or veteran who wishes to share their medical or dental records with another party should complete the DD 2870 form. This may include family members, healthcare providers, or legal representatives. By filling out this form, you maintain control over your health information while ensuring that necessary parties can access it when needed.
How do I complete the DD 2870 form?
Completing the DD 2870 form is straightforward. First, provide your personal information, including your name, Social Security number, and contact details. Next, specify the information you are authorizing to be disclosed. Clearly identify the recipient of this information and state the purpose for the disclosure. Finally, sign and date the form. Make sure to keep a copy for your records.
Where do I submit the DD 2870 form?
After completing the DD 2870 form, submit it to the appropriate medical or dental facility where your records are held. This could be a military treatment facility, a VA hospital, or another healthcare provider. It’s advisable to check with the facility for any specific submission guidelines they may have to ensure a smooth process.
The DD 2870 form, often used in military and veteran contexts, can be surrounded by misunderstandings. Here are four common misconceptions about this form:
Understanding these misconceptions can help individuals navigate the process of obtaining important military health records more effectively.
Incomplete Information: One of the most common mistakes is failing to fill out all required fields. Leaving any section blank can delay the processing of your request.
Incorrect Social Security Number: Entering the wrong Social Security number can lead to significant issues. Ensure that the number matches the one on your official documents.
Missing Signatures: It’s crucial to sign the form where indicated. A missing signature can render the entire form invalid, requiring resubmission.
Using Incorrect Dates: Providing incorrect dates, especially for the service member’s active duty dates, can cause confusion and delays in processing.
Failing to Provide Supporting Documents: Sometimes, additional documentation is necessary. Not including these can result in a request being denied or returned.
Not Reviewing for Accuracy: A simple review can catch errors. Double-checking your entries can save time and prevent complications.
Submitting Without a Copy: Always keep a copy of your completed form for your records. This can be helpful for future reference or in case of disputes.
Ignoring Submission Guidelines: Each branch may have specific submission protocols. Failing to follow these can lead to delays or rejection of your form.
Assuming the Form is Always the Same: The DD 2870 form can change. Always ensure you are using the most current version available to avoid outdated information.
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
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