Contents
The DD 2870 form, often referred to as the "Authorization for Disclosure of Medical or Dental Information," plays a crucial role in the management of medical records within the military healthcare system. This form serves as a formal request that allows service members and their dependents to authorize the release of their medical or dental information to specified individuals or entities. Understanding the importance of this document is essential, as it not only protects the privacy of the individual but also ensures that vital health information can be shared when necessary, such as during transitions in care or when seeking treatment from civilian providers. The DD 2870 is straightforward in its design, requiring the individual to provide personal details, specify the information to be disclosed, and identify the recipient of that information. Additionally, it outlines the duration of the authorization, ensuring that individuals maintain control over their medical data. This form is a vital tool that helps facilitate communication between healthcare providers while safeguarding the rights of service members and their families.
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Similar forms
The DD 2870 form is a request for medical records and related information. Several other documents serve similar purposes in different contexts. Here’s a list of nine documents that share similarities with the DD 2870 form:
- VA Form 10-5345: This form is used by veterans to request their medical records from the Department of Veterans Affairs. Like the DD 2870, it facilitates access to important health information.
- HIPAA Authorization Form: This document allows individuals to authorize the release of their health information. It ensures compliance with privacy regulations, similar to how the DD 2870 requests medical records.
- Form 21-4142: Used by veterans to authorize the release of private medical records, this form serves a purpose akin to the DD 2870 in obtaining necessary medical documentation.
- SF 180: This form is utilized to request military service records, including medical records. It parallels the DD 2870 in its aim to gather essential information from official sources.
- VA Form 21-526EZ: This application for disability compensation may require submission of medical records, similar to how the DD 2870 is used to support claims with medical documentation.
- Form 10-10EZ: This application for health benefits requests medical information, much like the DD 2870, to assess eligibility for services.
- WC-1 Georgia Form: This form, essential for workplace injury reporting, serves a similar purpose as the DD 2870. For more information, visit georgiapdf.com/wc-1-georgia/.
- Form 21-4138: This statement in support of a claim may include requests for medical records, reflecting a similar function to the DD 2870 in gathering evidence for claims.
- Form 22-5490: This application for survivor benefits may require medical documentation, paralleling the DD 2870 in its role in supporting claims with health records.
- DD Form 2005: This form is used to request medical records from the military. It shares the same goal as the DD 2870 of obtaining health information for various purposes.
Document 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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Form Specs
| 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 typically used by military personnel, veterans, and their authorized representatives. |
| Submission | The completed form must be submitted to the appropriate medical facility or records office. |
| Privacy Act Compliance | It complies with the Privacy Act of 1974, ensuring personal information is protected. |
| Signature Requirement | A signature is required from the individual authorizing the release of their medical records. |
| Expiration | The authorization remains valid until revoked or until a specified expiration date is reached. |
| State-Specific Forms | Some states may have their own forms for medical record release, governed by state laws. |
| Record Retention | Medical facilities are required to retain records for a specified period, depending on state laws. |
| Contact Information | Individuals should ensure their contact information is accurate on the form for follow-up. |
Crucial Questions on This Form
What is the DD 2870 form?
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is a document used by military personnel and their dependents. It allows them to authorize the release of their medical or dental records to specific individuals or organizations. This form ensures that sensitive health information is shared only with those who have permission to receive it.
Who needs to fill out the DD 2870 form?
Any active duty service member, reservist, or dependent seeking to share their medical or dental information must complete the DD 2870 form. This includes situations where records need to be sent to a healthcare provider, insurance company, or family member.
How do I complete the DD 2870 form?
To fill out the DD 2870 form, follow these steps:
- Download the form from the official military website or obtain a hard copy from a military medical facility.
- Provide your personal information, including your name, Social Security number, and contact details.
- Specify the individual or organization to whom you are granting access to your medical or dental records.
- Indicate the purpose of the disclosure.
- Sign and date the form to validate your authorization.
Where can I submit the DD 2870 form?
You can submit the completed DD 2870 form to the medical or dental facility that holds your records. This may be a military treatment facility or a civilian provider, depending on where you received care. Ensure that you keep a copy for your records.
Is there a fee associated with the DD 2870 form?
Generally, there is no fee for completing the DD 2870 form itself. However, if you request copies of your medical or dental records, there may be a fee charged by the facility for processing and copying those records. It’s best to inquire about any potential costs when you submit the form.
How long does it take for the records to be released after submitting the DD 2870 form?
The time it takes to process the DD 2870 form can vary. Typically, you can expect a response within 30 days. However, factors such as the facility's workload and the complexity of the request may affect this timeline. It's advisable to follow up if you haven’t received a response within that period.
Can I revoke my authorization after submitting the DD 2870 form?
Yes, you can revoke your authorization at any time. To do this, you should submit a written request to the facility where you submitted the DD 2870 form. Be sure to include your name, the date of the original authorization, and a statement indicating that you wish to revoke it.
What should I do if I have questions about the DD 2870 form?
If you have questions about completing or submitting the DD 2870 form, reach out to the medical or dental facility where you plan to submit it. They can provide guidance and clarify any concerns you may have about the process.
Documents used along the form
The DD 2870 form is a crucial document used primarily in military settings, specifically for requesting medical records or information. However, several other forms and documents often accompany it, ensuring a complete and thorough process. Below are five commonly used forms that may be needed alongside the DD 2870.
- DD Form 214: This form is known as the Certificate of Release or Discharge from Active Duty. It provides essential information about a service member's time in the military, including their discharge status, which can be important for accessing benefits or medical records.
- SF 180: The Standard Form 180 is used to request military records from the National Personnel Records Center. This form is particularly useful for veterans seeking copies of their service records or discharge documents.
- VA Form 21-526EZ: This is the Application for Disability Compensation and Related Compensation Benefits. Veterans may need to submit this form to apply for disability benefits, which could require access to their medical records.
- DD Form 2875: This form is used for system access requests and is essential for individuals needing access to the Defense Health Agency's electronic health record system. It may be relevant when seeking medical information.
- Notary Acknowledgement Form: Essential for verifying the authenticity of a signer's signature in various legal contexts. For more information, visit All Ohio Forms.
- HIPAA Authorization Form: This document grants permission for healthcare providers to share an individual's medical information with designated parties. It is often necessary for ensuring compliance with privacy regulations when requesting medical records.
Understanding these documents can help streamline the process of obtaining medical records or benefits. Each form serves a specific purpose and plays a vital role in ensuring that service members and veterans receive the support they need.
Misconceptions
The DD 2870 form is often misunderstood. Here are nine common misconceptions about this important document:
- The DD 2870 is only for military personnel. Many believe that only active duty members need to complete this form. In reality, eligible family members and veterans also need to fill it out for certain benefits.
- Completing the DD 2870 guarantees benefits. Some think that submitting the form automatically secures benefits. However, the form is just one part of the application process. Eligibility and approval depend on various factors.
- The DD 2870 is only required for healthcare services. While it is commonly associated with healthcare, it is also used for other benefits, such as education and housing assistance.
- You can submit the DD 2870 anytime. Many believe there are no deadlines. However, certain benefits have specific timeframes for submission. It is crucial to check the deadlines for each benefit.
- Once submitted, the DD 2870 cannot be changed. Some think that after submission, the information is set in stone. In fact, applicants can update their information if circumstances change.
- The form is the same for all branches of the military. There is a misconception that the DD 2870 is uniform across all military branches. Each branch may have its own version or specific requirements.
- Only the primary applicant needs to sign the form. Many assume that only the person applying for benefits needs to sign. However, dependent signatures may also be required in certain situations.
- You don’t need to provide supporting documents. Some think the DD 2870 stands alone. However, additional documentation may be necessary to support the application and prove eligibility.
- Once benefits are approved, the DD 2870 is no longer needed. Many believe that after receiving benefits, the form is irrelevant. In reality, it may be required for future applications or renewals.
Understanding these misconceptions can help ensure that the DD 2870 form is completed correctly and efficiently. This knowledge can lead to a smoother process when applying for benefits.