The DD 2870 form is a request for a medical evaluation and is commonly used within the military community. It plays a crucial role in ensuring that service members receive the necessary medical assessments. If you need to fill out this form, click the button below to get started.
The DD 2870 form plays a crucial role in the context of military and veteran healthcare, serving as a vital tool for individuals seeking access to medical services. This form is primarily used to authorize the release of health information, ensuring that medical providers can share necessary records with the appropriate parties. By filling out the DD 2870, service members and veterans grant permission for the disclosure of their medical history, which is essential for continuity of care. The form also includes sections that outline the specific information being released and the duration of the authorization. Understanding the implications of this form is important, as it impacts privacy rights and the flow of medical information. Individuals must complete the form accurately to avoid delays in receiving necessary healthcare services. Furthermore, familiarity with the DD 2870 can empower service members and veterans to make informed decisions about their health information and its management.
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is an important document used primarily by military personnel and their families. Here are some key takeaways to consider when filling out and using this form:
Understanding these points can help ensure that the process of obtaining medical or dental information is smooth and efficient.
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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What is the DD 2870 form?
The DD 2870 form is a Department of Defense document used to authorize the release of medical information. It allows service members and their dependents to grant permission for healthcare providers to share their medical records with designated individuals or organizations. This form is essential for ensuring that medical information is shared appropriately while maintaining patient confidentiality.
Who needs to fill out the DD 2870 form?
Any service member or dependent who wishes to authorize the release of their medical information should complete the DD 2870 form. This includes active duty personnel, reservists, retirees, and their eligible family members. It is particularly important when seeking treatment from outside military healthcare facilities or when coordinating care with other providers.
How do I obtain a DD 2870 form?
You can obtain the DD 2870 form through various channels. It is available online on the official Department of Defense website. You can also request a copy from your healthcare provider or military medical facility. Ensure you have the most current version of the form to avoid any issues with processing your request.
What information do I need to provide on the DD 2870 form?
The DD 2870 form requires several pieces of information. You will need to provide your personal details, including your name, Social Security number, and contact information. Additionally, you must specify the individual or organization to whom you are granting access to your medical records. Be prepared to indicate the purpose of the release and the type of information being shared.
Is there a deadline for submitting the DD 2870 form?
There is no specific deadline for submitting the DD 2870 form, but it is advisable to complete it as soon as you need to authorize the release of your medical information. Delays in submitting the form may impact your ability to receive timely medical care or share necessary information with other healthcare providers.
Can I revoke the authorization once I submit the DD 2870 form?
Yes, you can revoke the authorization at any time. To do so, you must provide a written notice to the individual or organization that received your medical information. Keep in mind that revoking the authorization will not affect any information that has already been shared prior to your revocation.
What happens if I do not fill out the DD 2870 form?
If you do not complete the DD 2870 form, your medical information cannot be released to the individuals or organizations you wish to share it with. This may hinder your ability to receive comprehensive care, especially if you are coordinating treatment with outside providers.
Can I fill out the DD 2870 form electronically?
Yes, the DD 2870 form can be filled out electronically if you have access to a computer or device that supports electronic signatures. However, be sure to check the specific requirements of the healthcare provider or organization requesting the form, as some may require a printed and signed copy.
Where do I submit the completed DD 2870 form?
You should submit the completed DD 2870 form to the healthcare provider or organization that will be receiving your medical information. This may include military treatment facilities, civilian healthcare providers, or insurance companies. Ensure you follow any specific submission guidelines they provide to avoid delays.
The DD 2870 form is an important document used in various military and government contexts, particularly for individuals seeking to authorize the release of their medical records. Alongside this form, several other documents and forms may be required to ensure a smooth process. Below is a list of common forms and documents that often accompany the DD 2870, each serving a specific purpose.
Each of these documents plays a vital role in facilitating various processes related to military service and healthcare. Understanding their purposes can help individuals navigate the complexities of military benefits and record management more effectively.
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When filling out the DD 2870 form, it’s important to approach the task with care and attention to detail. Here’s a list of things to keep in mind: