The DD 2870 form is a document used by the United States Department of Defense to authorize the release of medical information. This form is essential for service members and their families when seeking medical care or benefits. Understanding its purpose and proper completion can significantly streamline access to necessary health services.
The DD 2870 form plays a crucial role in the process of obtaining healthcare services for eligible individuals within the Department of Defense (DoD) community. Designed to facilitate the enrollment of dependents in the TRICARE program, this form ensures that families of military personnel have access to necessary medical care. By providing essential information about the beneficiary and their relationship to the service member, the DD 2870 form streamlines the administrative procedures involved in securing health benefits. It covers various aspects, including personal identification, eligibility criteria, and the necessary documentation required for enrollment. Understanding the significance of this form is vital for service members and their families, as it not only impacts their access to healthcare but also influences the overall well-being of those who serve and support our nation. Properly completing the DD 2870 can help avoid delays in receiving medical services and ensure that families receive the comprehensive care they deserve.
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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The DD 2870 form is a critical document used in various military and veteran-related processes, particularly for requesting medical records and other health information. Alongside this form, there are several other documents that may be required to ensure a smooth and complete application process. Below is a list of commonly used forms and documents that often accompany the DD 2870 form.
Having these documents ready can significantly streamline the process of applying for benefits or accessing medical records. It is always advisable to check the specific requirements for each situation, as additional documentation may be needed based on individual circumstances.
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The Illinois Rental Application form is a document used by landlords to gather essential information from prospective tenants. This form helps landlords assess the suitability of applicants for rental properties. By providing details such as employment history, credit information, and rental references, applicants can present themselves effectively in a competitive housing market. For additional assistance, landlords and tenants can refer to resources like Illinois Templates PDF.
T47 Form - Using the T-47 can simplify the process of verifying property information for buyers and sellers.
Melaleuca Cancellation Form - Updating your address is necessary if you've relocated.
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," serves a crucial role in the military healthcare system. Understanding how to fill out and utilize this form effectively can significantly impact the care and services received. Here are some key takeaways regarding the DD 2870 form:
By keeping these key points in mind, individuals can navigate the process of using the DD 2870 form with greater confidence and clarity.
The DD 2870 form is a Department of Defense document used to authorize the release of medical records and information. It is typically required when service members or their dependents seek medical care or benefits. This form ensures that healthcare providers have the necessary permissions to share personal health information with relevant parties.
The form must be completed by active duty service members, reservists, and their dependents when they want to access their medical records or authorize someone else to obtain them. This includes situations where individuals are seeking treatment or benefits that require verification of medical history.
To complete the DD 2870 form, follow these steps:
Ensure that all information is accurate to avoid delays in processing your request.
After completing the DD 2870 form, submit it to the medical facility that holds your records. This could be a military treatment facility or a civilian provider, depending on where you received care. It is advisable to keep a copy of the submitted form for your records.
Once the DD 2870 form is submitted, the medical facility will process your request. The time frame for processing can vary based on the facility and the complexity of the request. Generally, you should expect to receive the requested information or a response within a few weeks. If there are any issues or additional information is needed, the facility will contact you directly.
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 important document:
While the form is commonly used within military settings, it can also apply to family members and veterans seeking medical information.
This form specifically authorizes the release of medical or dental information related to the Department of Defense. It does not cover civilian medical records.
Individuals can revoke their authorization at any time, as long as they do so in writing. This ensures control over personal medical information.
The form is not limited to legal situations. It can also be used for personal requests for medical information, such as when changing healthcare providers.
The form allows individuals to specify what information they want released, ensuring that only relevant details are shared.
Many find the DD 2870 straightforward. The instructions are clear, and assistance is often available if needed.
Currently, the DD 2870 must be submitted in hard copy. Electronic submissions are not accepted, which can lead to confusion.
Authorizations typically expire after a certain period, often one year, unless otherwise specified. This protects individuals' privacy over time.
While the form does cover dental records, it is also specifically designed for medical information, making it applicable to a broad range of health-related data.
Understanding these misconceptions can help individuals navigate the process of obtaining medical information more effectively.