Table of Contents
The DD 2870 form is an essential document used primarily within the military and veteran communities, serving as a crucial tool for individuals seeking to access their medical records and other health-related information. This form is often required when service members or veterans need to authorize the release of their personal health information to designated individuals or organizations. By completing the DD 2870, individuals grant permission for healthcare providers to share their medical data, ensuring that they can receive appropriate care and support. The form also includes sections that allow for the specification of the types of information to be released, the duration of the authorization, and the parties involved in the disclosure. Understanding the importance of the DD 2870 is vital for those navigating the complexities of military healthcare systems, as it plays a significant role in safeguarding personal health information while facilitating necessary communication between healthcare providers and patients. Additionally, the form is designed to comply with federal privacy regulations, ensuring that the rights of service members and veterans are upheld throughout the process of obtaining their health records.
Document Specifics
| Fact Name | Description |
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| Purpose | The DD Form 2870 is used to authorize the release of medical information. |
| Who Uses It | This form is primarily used by military personnel and their dependents. |
| Submission | The completed form must be submitted to the appropriate medical facility or organization. |
| Validity | The authorization remains valid until revoked in writing or until a specified expiration date. |
| Confidentiality | Information released under this form is protected under HIPAA regulations. |
| State-Specific Laws | Some states have additional laws governing medical records; for example, California's Confidentiality of Medical Information Act. |
| Signature Requirement | A signature is required from the individual authorizing the release of their medical information. |
Similar forms
The DD 2870 form is used primarily for requesting access to medical records and health information within the military context. Several other documents serve similar purposes in various contexts. Here are seven documents that share similarities with the DD 2870 form:
- HIPAA Authorization Form: This form allows individuals to authorize the release of their medical records to designated parties. Like the DD 2870, it ensures that personal health information is shared only with consent.
- VA Form 10-5345: Used by veterans, this form requests the release of medical records from the Department of Veterans Affairs. It functions similarly to the DD 2870 in that it facilitates access to health information.
- Release of Information Form: Commonly utilized in healthcare settings, this form allows patients to release their medical information to third parties. It parallels the DD 2870 by emphasizing the need for patient consent.
- Transfer-on-Death Deed: This form enables property owners to designate beneficiaries for their assets without going through probate, similar to how other documents facilitate the transfer of important information like the Arizona PDF Forms.
- Patient Authorization for Release of Health Information: This document is often required by hospitals and clinics to release a patient’s medical records. It shares the same fundamental purpose of obtaining permission before sharing sensitive information.
- Form 21-4142: This is a VA form used by veterans to authorize the release of their private medical records. It is similar to the DD 2870 in its focus on health information access.
- Medical Records Request Form: Often used by patients to obtain copies of their health records, this form functions similarly to the DD 2870 by facilitating access to personal health data.
- Consent to Release Information Form: This form is utilized in various settings to gain consent from individuals before sharing their information. It parallels the DD 2870 in its emphasis on consent and confidentiality.
DD 2870 Example
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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Understanding DD 2870
What is the DD 2870 form?
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is used by military personnel and their dependents. This form allows individuals to authorize the release of their medical or dental records to specified parties, such as healthcare providers or insurance companies. It ensures that sensitive health information is shared only with authorized individuals or entities.
Who needs to fill out the DD 2870 form?
Anyone who wishes to authorize the release of their medical or dental information must complete the DD 2870 form. This includes active duty service members, reservists, veterans, and their dependents. If you need to share your health records for treatment, insurance purposes, or legal matters, this form is essential.
How do I complete the DD 2870 form?
To complete the DD 2870 form, first, download it from the official military website or obtain a copy from your healthcare provider. Fill in your personal information, including your name, Social Security number, and contact details. Specify the individual or organization you are authorizing to receive your medical records. Finally, sign and date the form to validate your request. 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 facility or healthcare provider that holds your records. Each facility may have its own submission process, so check with them for specific instructions. You can typically submit the form in person, via mail, or sometimes electronically, depending on the facility's policies.
How long does it take to process the DD 2870 form?
The processing time for the DD 2870 form can vary depending on the medical facility and the complexity of the request. Generally, it may take anywhere from a few days to several weeks. If you need your records urgently, consider contacting the facility directly to inquire about expedited processing options.
Can I revoke my authorization after submitting the DD 2870 form?
Yes, you can revoke your authorization at any time. To do this, you must submit a written request to the same facility or individual to whom you initially authorized the release of your records. Make sure to include your name, the date of the original authorization, and a statement indicating that you wish to revoke your authorization. Keep in mind that revoking your authorization will not affect any disclosures made before the revocation was received.
Dos and Don'ts
When filling out the DD 2870 form, it’s important to follow certain guidelines to ensure accuracy and compliance. Below are some recommended actions and common pitfalls to avoid.
- Do read the instructions carefully before starting.
- Do provide accurate personal information.
- Do double-check all entries for errors.
- Do sign and date the form where required.
- Don't leave any required fields blank.
- Don't use abbreviations unless specified.
- Don't submit the form without reviewing it.
- Don't forget to keep a copy for your records.
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