The DD 2870 form is a request for medical and dental records from the Department of Defense. This form is essential for service members and veterans seeking access to their health information. To ensure you receive your records promptly, fill out the form by clicking the button below.
The DD 2870 form plays a crucial role in the realm of military benefits and healthcare services. It serves as a request for information that enables service members, veterans, and eligible dependents to access various health care benefits through the Department of Defense. By completing this form, individuals can facilitate their enrollment in the Defense Enrollment Eligibility Reporting System (DEERS), which is essential for obtaining medical care and other related services. The form not only streamlines the process of verifying eligibility but also ensures that beneficiaries receive the necessary support in a timely manner. Understanding the key components of the DD 2870 form is vital for anyone seeking to navigate the complexities of military healthcare benefits. It is designed to capture essential personal information, including the individual's relationship to the service member and specific details about their eligibility. Properly filling out this form can significantly impact access to healthcare resources, making it an important document for those connected to the military community.
Guardianship Documents - It's beneficial for ensuring a child's emotional security during changes.
For those looking to facilitate a smooth transaction, our guide on how to create a trailer bill of sale document is invaluable. You can find more details by visiting how to effectively prepare your Trailer Bill of Sale.
Replacement Title Alabama - Supporting documents must include the current Alabama title for the vehicle.
Roof Certification Form - Document any water stains observed on the walls.
When filling out and using the DD 2870 form, consider these key takeaways:
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
Reset