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Blank DD 2870 PDF Form

The DD 2870 form, known formally as Authorization for Disclosure of Medical or Dental Information, is a document used by individuals to authorize the release of their medical or dental records within the United States Department of Defense. This form serves as a bridge for the secure and compliant sharing of health information between military healthcare providers and authorized recipients, ensuring that sensitive data is handled with the utmost care and discretion. For those needing to navigate the process of sharing their health records, completing the DD 2870 is a critical step; click the button below to learn more about how to fill out this form.

Content Overview

When individuals or families navigate the complexities of accessing and managing military medical records, one crucial tool at their disposal is the DD 2870 form. This form fundamentally serves as an authorization for the disclosure of information, playing a pivotal role in ensuring that military personnel and their dependents can grant consent for the release of their medical or dental records to requested parties. The essence of the DD 2870 form lies in its ability to bridge the privacy of patients with the necessity of sharing medical information under specific circumstances, such as for continuing healthcare, processing insurance claims, or even facilitating medical board proceedings. By properly completing and submitting this form, service members take an important step towards managing their healthcare more effectively, maintaining control over who has access to their sensitive medical information. Understanding the appropriate way to fill out and use the form unlocks the potential for a smoother interaction with healthcare providers and administrative processes, making it a critical aspect of healthcare management within the military community.

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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			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
DD FORM 2870, DEC 2003		Reset
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Form Specifications

Fact Number	Description
1	The DD 2870 form is titled Authorization for Disclosure of Medical or Dental Information.
2	It is used by military members, veterans, and their dependents to authorize the release of medical or dental information by military health care providers.
3	The form allows individuals to specify which information can be disclosed, including the date range of the medical records to be released.
4	Filling out the DD 2870 properly is necessary to ensure that only authorized parties receive sensitive health information.
5	The form requires the identification of the individual whose records are to be disclosed, the organization receiving the disclosure, and the purpose of the disclosure.
6	A signature from the patient or their legal representative, along with the date, is mandatory to validate the authorization.
7	There are no state-specific versions of the DD 2870 form as it is a federal document used across the United States within the Department of Defense.
8	Once completed, the form should be submitted to the appropriate medical facility's records department or the designated point of contact.

DD 2870: Usage Guidelines

Upon deciding to fill out the DD 2870 form, it's crucial to approach the task with attention to detail. This document plays a pivotal role in ensuring that the designated processes are conducted smoothly, enabling all involved parties to proceed with clarity and understanding. The completion of this form, therefore, must be approached methodically, ensuring all data provided is accurate and comprehensive. Below are the steps designed to guide individuals through the process, ensuring a thorough and correct submission.

Start by gathering all necessary information related to the subject matter of the DD 2870 form. This includes personal identification details, contact information, and any other specifics pertinent to the form's context.
Locate the official DD 2870 form document. This can typically be found through relevant departmental websites or by contacting the appropriate administrative office directly for guidance.
Read through the entire form before beginning to fill it out. This preliminary review helps familiarize oneself with the form's layout, requirements, and the nature of information requested.
Fill in the personal information section at the top of the form. This typically includes name, address, date of birth, and other identifiers. Ensure this information is complete and matches official documents.
Proceed to fill out the contact information section, providing current and accurate details for communication purposes. This could include phone numbers, email addresses, and mailing addresses.
Address the specifics of the request or action required by the DD 2870 form. This part often requires detailed information regarding the situation or services requested. Provide clear, concise details to avoid misunderstandings.
Review the form for completeness and accuracy. Double-check all entries for errors or omissions, ensuring that the information provided aligns with the form's requirements.
Sign and date the form in the designated areas, as this acts as confirmation of the accuracy of the information provided and authorizes the requisite actions.
If applicable, include any required supporting documentation or additional forms that are requested or necessary for the processing of the DD 2870 form.
Submit the completed form to the appropriate department or office as directed in the form's instructions. This may include mailing, faxing, or electronic submission, depending on the specific protocols of the organization.

Following submission, it is advisable to keep a copy of the completed form and any confirmations of receipt for personal records. This ensures that one has evidence of the submission and can follow up appropriately, should there be any inquiries or need for further action. The process of filling out and submitting the DD 2870 form, while meticulous, is a crucial step in facilitating the intended administrative or operational actions, and as such, warrants careful attention to each detail.

Common mistakes

When individuals set out to fill the DD 2870 form, which is used to request medical or dental records from military facilities, several common mistakes can occur. These errors can lead to delays in the processing of requests, or in some cases, the denial of the request altogether. It's important to approach this document with care to ensure all the necessary information is correctly provided. Here is an expanded list of six common mistakes made:

Not verifying eligibility before submission: Many individuals assume they are automatically eligible to receive records without first verifying their eligibility. This mistake can lead to the rejection of their request.
Incorrect or incomplete personal information: It’s crucial to double-check that all personal information, including full name, social security number, and date of birth, is correct and fully filled out. Misinformation or incomplete fields can prevent the request from being processed.
Failing to specify the records needed: The DD 2870 form requires the requester to specify which medical or dental records are needed. A common mistake is not being specific enough about the records required, leading to incomplete fulfillment of the request.
Omitting the purpose of the request: The form asks for the reason for the records request. Neglecting to state the purpose can cause delays, as officials may need to clarify the intention behind the request before processing.
Not including the correct mailing address: If the requester fails to provide a correct and complete mailing address where the records should be sent, it can result in the records being sent to the wrong place or not being sent at all.
Forgetting to sign and date the form: One of the simplest yet most frequently made mistakes is not signing or dating the form. A signature is required to validate the request, and without it, the process cannot proceed.

Avoiding these mistakes can significantly streamline the process of obtaining medical or dental records through the DD 2870 form. Ensuring all information is accurate and complete before submission is key to a successful request.

Documents used along the form

When you're navigating the maze of paperwork and forms required for various legal, medical, and governmental processes, understanding the context and companions of each form can significantly ease your journey. The DD Form 2870, or "Authorization for Disclosure of Medical or Dental Information," is frequently utilized within the military sector to authorize the release of health information. However, it is often accompanied by other documentation, each serving its unique purpose in ensuring that all necessary information is accurately communicated and legally documented. Understanding these companion documents can help streamline the process and ensure no detail is overlooked.

Privacy Act Statement: Prior to filling out the DD 2870, individuals are typically presented with a Privacy Act Statement. This document explains how the federal government will use the personal information it collects and the individual's rights under the Privacy Act of 1974.
Health Insurance Portability and Accountability Act (HIPAA) Authorization Form: Similar to the DD 2870, the HIPAA Authorization Form is used in civilian healthcare to authorize the release of an individual’s health information. It ensures the process adheres to HIPAA regulations, protecting the privacy of the patient.
Proof of Power of Attorney (POA): If the DD 2870 is being submitted by someone other than the patient, proof of Power of Attorney may be required to verify the individual's authority to request and receive medical or dental information.
Medical Records Release Form: For the transfer of records between facilities or providers not covered by a direct DD 2870 submission, a separate Medical Records Release Form specific to the institution might be necessary.
Service Treatment Record (STR): When requesting medical records, the requester may need to specify the inclusion of the Service Treatment Record, which contains the medical history of service members during their active duty.
Proof of Identity: To prevent unauthorized access to sensitive information, proof of identity (such as a government-issued ID card) is often required when submitting the DD 2870.
Incident Report: In cases where the request for information is related to a specific incident, such as an injury in the line of duty, an incident report may need to be submitted alongside the DD 2870.
DD Form 214: Upon the transition from military service, a DD Form 214 is issued, summarizing the service member's career. This form may be required for context or verification when accessing medical records post-service.
Request for Information Form: Some institutions may require a specific Request for Information Form in addition to the DD 2870 to detail the scope and nature of the information being requested.
Patient Consent Form: Particularly in cases involving the sharing of sensitive or protected health information, a separate Patient Consent Form might be needed to explicitly document the patient's consent to share their information.

The intricate interplay between the DD 2870 and its often-required accompanying documents underscores the importance of a thorough preparation process. Whether you're a service member, a veteran, or acting on behalf of one, understanding these additional documents ensures a smoother navigation through the procedural aspects of accessing medical and dental information. While the specific requirements may vary based on the situation and jurisdiction, being prepared with a comprehensive set of documents will facilitate a more efficient and secure information disclosure process.

Similar forms

Health Insurance Portability and Accountability Act (HIPAA) Authorization Form: Similar to the DD 2870 form, the HIPAA Authorization Form is used to authorize the release of an individual's health information. Both documents require specific details about the individual whose information is being disclosed, the nature of the information to be released, and the purpose of the disclosure. They ensure that personal health information is shared securely and in compliance with federal privacy laws.
Medical Records Release Form: This form, like the DD 2870, permits healthcare providers to share a patient's medical records with specified individuals or organizations. The primary similarity lies in their function to facilitate the transfer of protected health information, contingent upon the patient's consent. Both forms delineate the scope and limitations of the information to be disclosed.
Power of Attorney for Health Care: While the Power of Attorney for Health Care primarily designates an individual to make healthcare decisions on behalf of someone else, it is similar to the DD 2870 in that it involves granting permissions related to personal health information. Both documents play vital roles in ensuring a person's health care preferences are honored and that trusted parties can access necessary information for decision-making.
General Consent Form for Medical Treatment: This form shares its purpose with the DD 2870 in the context of granting permission, albeit more broadly for medical treatment rather than the release of medical records. They are both integral to the medical process, ensuring that patients or their representatives agree to specific actions concerning their health care.
Privacy Act Release Form: Much like the DD 2870, this document is used to authorize the disclosure of personal information, but under the provisions of the Privacy Act. Both forms require clear consent from the individual for their information to be shared, highlighting the individual's control over their personal data.
Consent to Release Financial Information Form: Although this form focuses on financial rather than health information, it parallels the DD 2870 in its function to authorize the sharing of private data. Each document mandates explicit permission from the individual for certain information to be disclosed to designated parties.
Authorization for Release of Employment Information Form: This form is akin to the DD 2870 in that it permits the disclosure of an individual's employment-related details. Both forms facilitate the exchange of sensitive information, emphasizing the necessity for the individual's consent and defining the scope of the disclosure.

Dos and Don'ts

The DD Form 2870, also known as the Authorization for Disclosure of Medical or Dental Information, is a document used within the Department of Defense. It is filled out when an individual wishes to allow the release of their medical or dental records to a designated person or entity. Handling this form properly ensures that personal health information is shared respectfully and securely. Here are six dos and don'ts to consider when completing the DD 2870 form.

Things You Should Do:

Read the instructions carefully before you start filling out the form to ensure you understand the requirements and the type of information needed.
Use black ink and write legibly to ensure that all information is clear and understandable, minimizing the risk of errors or delays.
Verify that you have the correct version of the form, as outdated forms may not be accepted and could lead to the rejection of your request.
Include all necessary details, such as your full name, date of birth, social security number, and the specific records you are requesting to be released.
Sign and date the form in the designated area to provide the required authorization for the release of your medical or dental records.
Keep a copy of the completed form for your records, as this will help you track the request and address any issues that may arise.

Things You Shouldn't Do:

Do not leave any required fields empty. Incomplete forms might delay or prevent the processing of your request.
Do not forget to specify the purpose of the disclosure. Vague descriptions can lead to confusion and potential misuse of your information.
Avoid using pencil or colors of ink other than black, as this can cause issues with scanning or photocopying the form.
Do not guess information; if you are unsure about a detail, verify it before completing the form to avoid inaccuracies.
Refrain from providing more information than what is requested. Over-disclosing can lead to unnecessary exposure of personal health information.
Do not forget to review the form for errors or omissions before submitting it. Mistakes could lead to delays or rejection of your authorization request.

Misconceptions

The DD 2870 form is often surrounded by misconceptions that can lead to confusion. To ensure clarity, let's address some of these misunderstandings directly.

It's available for non-military use: The DD 2870 form is specifically designed for military members, their families, and retirees to request the release of medical or dental information. It is not intended for use by the general public.
It covers all medical records automatically: Completing a DD 2870 form does not grant access to all medical records by default. The form requires specification of the types of records needed, and only those authorized will be released.
Parental consent isn't required for minors: For dependents under the age of 18, parental or legal guardian consent is necessary when requesting medical information via the DD 2870 form.
Signing the form waives all HIPAA protections: Filling out and signing the DD 2870 does not waive all HIPAA protections. It authorizes the release of specific information to individuals or organizations named in the form, in accordance with HIPAA regulations.
There is a filing fee: There is no fee to submit a DD 2870 form. The process of requesting medical records through this form is free of charge for eligible individuals.
Electronic signatures are not accepted: Depending on the institution and its capabilities, electronic signatures on a DD 2870 form can be accepted. It's essential to confirm with the specific medical records department.
Any healthcare provider can sign off on requests: Only the healthcare provider who is either primarily responsible for the patient’s care or is the head of the department that maintains the records can legally endorse requests made on the DD 2870 form.
The form offers instant access to records: Submitting a DD 2870 form does not guarantee immediate access to medical records. The processing time can vary depending on the facility’s policy, the volume of requests, and the specific information being requested.

Understanding these key points can alleviate common concerns and misconceptions regarding the DD 2870 form, ensuring smoother interactions and processes for those who need to use it.

Key takeaways

The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," serves as a critical tool for individuals seeking to grant permission for the release of their health information. Understanding how to properly fill out and use this form ensures individuals maintain control over their personal health information while complying with legal standards. The process may seem daunting initially, but grasping a few key takeaways can simplify it significantly.

Accurate Information is Crucial: The first takeaway emphasizes the importance of filling out the form with accurate and complete information. This includes the patient's full name, date of birth, social security number, and the specific health records they agree to disclose. Attention to detail ensures the information is processed efficiently and correctly, mitigating the risk of delays or errors in sharing vital health data.
Specify the Scope of Disclosure: It's essential that individuals clearly define which part of their medical or dental records can be disclosed. This specificity helps in protecting privacy by ensuring only the necessary information is shared. Whether the authorization pertains to all health records or just specific parts, like laboratory reports or a particular treatment summary, this precision is critical.
Understand the Expiration Date: Every authorization has an expiration. The DD 2870 form requires the person completing it to specify until when the authorization remains valid. This could either be a set date or an event that triggers the end of the authorization, such as the completion of a medical claim. Being aware of this expiration date is important for both the individual sharing their information and the entity receiving it, as it delineates the timeframe for which the consent is valid.
Review and Update as Necessary: Circumstances change, and as they do, it might be necessary to update the authorization regarding what health information can be disclosed. Reviewing the permissions granted periodically ensures that they continue to reflect the individual's current wishes and circumstances. In cases where changes are necessary, a new DD 2870 form must be completed and submitted to replace the previous authorization.

By understanding and following these key takeaways, individuals can navigate the complexities of sharing their health information with confidence, ensuring that their privacy is protected while allowing necessary access to their medical or dental records.