Contents
The DD 2870 form is a crucial document in the context of military health care services, specifically pertaining to the release of health information. Designed for both active duty service members and their eligible family members, this form serves to authorize the sharing of personal health records. Its primary function is to ensure that individuals can access their medical information while allowing health care providers to communicate relevant details when necessary. Completing the DD 2870 is essential for maintaining accurate and up-to-date health records, which can directly impact medical treatment and care continuity. The process of completing and submitting the form is straightforward, offering a vital mechanism for safeguarding personal health privacy while facilitating the necessary flow of information during medical engagements. Understanding the importance of the DD 2870 form is key for both service members and their families, who rely on efficient and effective health care services.
Sample - DD 2870 Form
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
AUTHORITY: Public Law
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
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) |
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2. DATE OF BIRTH (YYYYMMDD) |
3. SOCIAL SECURITY NUMBER |
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4. PERIOD OF TREATMENT: FROM - TO (YYYYMMDD) |
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5. TYPE OF TREATMENT (X one) |
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OUTPATIENT |
INPATIENT |
BOTH |
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SECTION II - |
DISCLOSURE |
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6. I AUTHORIZE |
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TO RELEASE MY PATIENT INFORMATION TO: |
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(Name of Facility/TRICARE Health Plan) |
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a. NAME OF PERSON OR ORGANIZATION TO RECEIVE MY |
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b. ADDRESS (Street, City, State and ZIP Code) |
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MEDICAL INFORMATION |
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c. TELEPHONE (Include Area Code) |
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d. FAX (Include Area Code) |
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7. REASON FOR REQUEST/USE OF MEDICAL INFORMATION (X as applicable) |
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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) |
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(If applicable) |
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SECTION IV - FOR STAFF USE ONLY (To be |
completed only upon receipt of written revocation) |
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14. X IF APPLICABLE:
AUTHORIZATION REVOKED
15. REVOCATION COMPLETED BY
16.DATE (YYYYMMDD)
17. IMPRINT OF PATIENT IDENTIFICATION PLATE WHEN AVAILABLE |
SPONSOR NAME: |
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SPONSOR RANK: |
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FMP/SPONSOR SSN: |
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BRANCH OF SERVICE: |
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PHONE NUMBER: |
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DD FORM 2870, DEC 2003 |
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Form Information
| Fact Name | Description |
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| What is DD Form 2870? | It is a form used for authorization to release medical information for service members and veterans. |
| Purpose of the Form | DD Form 2870 allows service members to grant permission to healthcare providers to share their medical records. |
| Who Can Use It? | Active duty service members, veterans, and eligible family members can use this form. |
| Governing Law | The use of DD Form 2870 is governed by federal law, specifically the Health Insurance Portability and Accountability Act (HIPAA). |
| Filing Process | The completed form should be submitted to the designated healthcare facility or provider that holds the medical records. |
| Expiration of Authorization | The authorization remains valid until a specified date is reached or the subject revokes it. |
| Benefits of Using the Form | It provides a legal method for individuals to manage the privacy of their medical information. |
| Where to Obtain | DD Form 2870 is available online through official military and veteran service websites. |
| Consequences of Non-Submission | Failure to submit the form may result in delays in receiving care or accessing medical records. |
Detailed Guide for Filling Out DD 2870
Preparing to fill out the DD 2870 form can seem overwhelming, but by following a clear set of instructions, you can complete it accurately and efficiently. Once you have correctly filled out the form, be sure to review it for any errors and ensure that all required information is included before submission.
- Begin by downloading the DD 2870 form from an official source, or obtain a physical copy if preferred.
- Read through the entire form to familiarize yourself with its sections and requirements.
- Fill in your personal information at the top section, including your full name, date of birth, and social security number, if required.
- Provide your contact details including your mailing address, phone number, and email address in the designated spaces.
- Carefully answer the questions in the form as they apply to your situation. Ensure you provide complete and accurate information.
- If applicable, indicate any additional information or special circumstances that may be pertinent to your case in the comments section.
- Review the filled out form for accuracy and completeness. Double-check all information for spelling errors or omissions.
- Sign and date the form where indicated, confirming that the information provided is true to the best of your knowledge.
- Make a copy of the filled-out form for your records before submission.
- Submit the completed form as instructed, following any guidelines provided for the specific submission method required.
Obtain Answers on DD 2870
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What is the DD 2870 form?
The DD 2870 form is a document used by the Department of Defense (DoD) for Service Members, their families, and other eligible individuals to request access to their medical records. It serves as a formal request so that individuals can obtain necessary health information or medical treatment records.
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Who needs to fill out the DD 2870 form?
This form is typically filled out by Service Members, veterans, and eligible family members who need to access their personal health information. Providers or facilities managing medical records may also complete this form on behalf of the individual, but the original request still requires the affected person's consent.
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How do I submit the DD 2870 form once completed?
After filling out the DD 2870 form, submit it to the appropriate medical facility where your records are held. Each facility may have a specific process for submission. Generally, you can deliver it in person, send it via mail, or submit it electronically, depending on the options available.
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What should I do if I have questions about the DD 2870 form?
If you have questions while filling out the DD 2870 form, it is advisable to contact the medical facility's record management office directly. They can provide guidance on how to properly complete the form and address any concerns about the process. Additionally, military support services are available to assist Service Members and their families.
Common mistakes
Filling out the DD 2870 form can be a complex process, and there are several common mistakes that individuals often make. One prevalent error is not reading the instructions carefully. The form has specific guidelines that detail how to complete it properly. Skipping over these instructions can lead to incorrect submissions, which may delay the process or require resubmission.
Another common mistake is providing incomplete information. The DD 2870 form requires various personal details, including contact information and specific data related to the request. Omitting any of these essential details can cause complications and hamper the efficiency of the request. It’s crucial to ensure that all sections of the form are filled in thoroughly.
Many individuals underestimate the importance of signatures and dates. A frequent oversight is neglecting to sign the form or failing to date it accurately. An unsigned or undated form is typically considered invalid, which can thwart the intended purpose of the request. Attention should be given to these small yet significant details.
Another mistake often made is submitting the form without double-checking for errors. Typos or incorrect information can occur easily, but they can lead to significant issues. Taking the time to review the completed form before submission can help catch mistakes that could otherwise impede progress.
In some instances, individuals may not provide the required supporting documentation along with their DD 2870 form. This oversight can result in delays as the responsible agency may not process the request until all necessary accompanying documents are received. Understanding what additional documentation may be needed is important for a smooth submission.
People sometimes misuse the form by filling out sections that do not apply to their specific situation. Misinterpretation of the sections can lead to confusion, and incorrect information may be submitted. It’s beneficial to take a careful look at each section to determine what applies.
Another common issue is failing to keep copies of the submitted form. After filling out the DD 2870, individuals might forget to make a duplicate or retain a digital version for their records. Having a copy can be immensely useful for tracking purposes and in case any questions or issues arise later.
Lastly, failing to follow up after submission is a mistake some individuals make. After sending in the DD 2870 form, it’s wise to check in with the relevant agency to confirm that the form was received and is being processed. This step not only ensures clarity but also demonstrates proactive engagement.
Documents used along the form
The DD 2870 form, formally known as the "Authorization for Disclosure of Medical or Dental Information," is crucial for obtaining medical or dental records. This form often accompanies several other documents and forms in various processes. Below are some commonly used forms that may accompany the DD 2870, each serving a specific purpose in facilitating information requests or medical processes.
- DD Form 214: This form provides a service member's record of military service. It's essential for verifying eligibility for benefits and services.
- SF 180: The Standard Form 180 allows veterans to request their military records, including their DD 214. It streamlines the process for receiving documentation.
- VA Form 21-526: This is the application for disability compensation and related benefits. It helps veterans initiate claims for additional resources based on their service-related conditions.
- HIPAA Release Form: This document permits healthcare providers to share personal health information with designated individuals. It's essential for ensuring privacy and consent in disclosures.
- Authorization for Release of Information: This form grants permission to release specific personal data from a medical provider, necessary for comprehensive medical care assessments.
- DD Form 615: This is a "Application for Travel Allowance" form, frequently used for reimbursement requests related to travel for medical appointments.
- VA Form 21-4138: Known as the Statement in Support of Claim, this form provides additional information relevant to a veteran's claim and can strengthen the case for benefits.
- VA Form 10-10EZ: This application for the Federal Benefits Application helps veterans enroll in the VA health care system, crucial for accessing benefits.
- Power of Attorney Form: This legal document designates an individual to make decisions on behalf of another person, often necessary for managing medical care and benefits.
Understanding these documents can simplify the process for those navigating healthcare and benefits related to military service. Each form plays a unique role in ensuring individuals receive the proper support and care they deserve.
Similar forms
The DD 2870 form, which is primarily used to authorize the release of information for a variety of purposes, shares similarities with several other documents. Below are seven documents that possess comparable functions or features:
- Standard Form 180 (SF-180) - This form is utilized to request military records from the National Personnel Records Center. Like the DD 2870, it facilitates the release of sensitive personal information.
- DD Form 214 - This document summarizes military service. While it primarily establishes service records, it often requires consent for the release of information to third parties.
- Authorization for Release of Health Information (HIPAA release form) - This form allows healthcare providers to share medical records. Similar to DD 2870, it requires specific consent for the release of confidential information.
- Veterans Affairs Form 21-4142 - Used for authorizing the release of private medical records to the VA, this document mirrors DD 2870 in its intent to ensure information is shared legally and responsibly.
- Public Records Request - This formal request seeks access to public records. Just as with DD 2870, it requires specified permissions to protect the rights of individuals involved.
- Consent to Release Information (Student Education Records) - This form is necessary for schools to disclose student information. Like DD 2870, it emphasizes the importance of consent in sharing sensitive data.
- Authorization Form for Release of Information (Employment Background Checks) - This document is used by employers to obtain background check data. Similar to DD 2870, it involves obtaining permission to access personal information.
Dos and Don'ts
Filling out the DD 2870 form requires attention to detail. Below are some important dos and don’ts to consider:
- Do read the instructions carefully before starting the form.
- Do provide accurate and complete information to avoid delays.
- Do double-check your entries for any mistakes.
- Do ensure that you sign and date the form where required.
- Don't leave any required fields blank.
- Don't use correction fluid or tape on the form.
- Don't submit the form without reviewing all the information.
- Don't rely on memory; gather all necessary documents beforehand.
Misconceptions
The DD 2870 form is essential for individuals engaged with the military healthcare system, and yet several misconceptions surround it. Understanding the true nature of this form can elucidate its significance and usage. Below are five common misconceptions:
- The DD 2870 form is only for active duty service members. Many believe that only those currently serving need the form. In reality, it is also applicable to veterans and their family members who wish to access healthcare services.
- All medical facilities recognize the DD 2870. There is a misconception that all healthcare providers will accept the DD 2870 without question. However, the acceptance of this form can vary; some facilities may have their own preferred forms or procedures.
- The DD 2870 must be filled out every time a medical appointment is made. It is commonly thought that the form needs to be completed for each visit. Instead, the form is generally a one-time submission unless changes to the consent are required.
- Signing the DD 2870 relinquishes personal privacy. Many assume that completing the form means losing control over personal health information. However, the form actually safeguards privacy by outlining how information is handled, ensuring individuals are informed.
By dispelling these misconceptions, individuals can better navigate the healthcare services related to the military, ensuring they understand their rights and responsibilities when using the DD 2870 form.
Key takeaways
The DD 2870 form is an important document used primarily for requesting access to military medical records. Below are key takeaways for filling out and using this form:
- Ensure all personal information is accurate. This includes your full name, Social Security number, and contact details.
- Check the eligibility requirements. Only individuals who meet specific criteria can request access to records.
- Clearly specify the records you wish to access. This will help expedite the processing of your request.
- Be aware of potential fees. There may be costs associated with retrieving and copying records.
- Submit the form to the correct office. Confirm the appropriate address for submission to avoid delays.
- Keep a copy of the completed form for your records. This serves as proof of your request.
- Follow up if there is no response within a reasonable timeframe. Persistence can be necessary.
- Understand your rights regarding privacy. Personal health information is protected under specific laws.
- Consider the assistance of a representative if needed. They can help navigate the process and answer questions.
- Utilize online resources for additional guidance. Official military websites provide valuable information about the form and its use.
Using the DD 2870 form correctly ensures that you can access important medical records efficiently and effectively.
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