The DD 2870 form is a document used by the U.S. Department of Defense to authorize the release of medical information. This form is crucial for service members and their families, as it ensures that necessary health data can be shared with appropriate parties. Understanding how to fill out this form correctly is essential for maintaining access to vital health services.
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The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is a document used by the Department of Defense. It allows military personnel and their dependents to authorize the release of their medical or dental records. This form is essential for ensuring that healthcare providers have the necessary permissions to share patient information with other entities, such as insurance companies or other healthcare facilities.
Any active duty service member, reserve member, or dependent seeking to have their medical or dental information disclosed should complete the DD 2870 form. This includes family members who may need to share their health records for various reasons, such as transferring care to a new provider or applying for benefits.
The DD 2870 form can typically be obtained online through the official Department of Defense website or directly from military healthcare facilities. It is often available at hospitals, clinics, or through military health system portals. Additionally, you may request a copy from your healthcare provider if you are unsure where to find it.
When filling out the DD 2870 form, you will need to provide various details, including:
The authorization granted by the DD 2870 form is generally valid for one year from the date it is signed. After that period, a new form must be completed to continue the disclosure of medical or dental information. It is important to keep track of the expiration date to avoid any interruptions in care or access to records.
If you decide to revoke your authorization after submitting the DD 2870 form, you must do so in writing. A letter stating your intention to withdraw the authorization should be sent to the same entity that received your original authorization. Ensure you include relevant details, such as your name, the date of the original authorization, and any other identifying information to facilitate the process.
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is an important document for individuals seeking access to their medical records within the military healthcare system. It is often accompanied by other forms that facilitate the process of obtaining medical information or services. Below are some commonly used forms and documents that may accompany the DD 2870.
Understanding these forms can streamline the process of accessing medical information and ensure that individuals receive the care they need. Each document plays a crucial role in the overall system of military healthcare, helping to maintain transparency and accessibility for service members and veterans alike.
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
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Filling out the DD 2870 form can be a straightforward process, but mistakes can lead to delays or complications. One common error is failing to provide accurate personal information. Individuals often overlook the importance of double-checking their name, Social Security number, and contact information. Even a small typo can cause significant issues in processing the application.
Another frequent mistake is not signing the form. Many people may forget to include their signature at the bottom, which is essential for validating the application. Without a signature, the form may be considered incomplete, resulting in additional requests for information and prolonging the process.
Some individuals may also misinterpret the instructions regarding the required documentation. It is crucial to review the checklist thoroughly and ensure that all necessary documents are included with the submission. Omitting required documents can lead to delays and may necessitate resubmission of the entire application.
In addition, individuals sometimes fail to specify their relationship to the service member or veteran correctly. This information is vital for determining eligibility for benefits. Misidentifying the relationship can lead to complications in processing the claim.
Another mistake involves not keeping a copy of the completed form. It is always advisable to retain a copy for personal records. This can be helpful if there are questions or issues that arise later in the process, allowing for easier reference.
Finally, some people may neglect to follow up on their application status. After submitting the DD 2870 form, it is important to check in periodically. This ensures that any potential issues can be addressed promptly, preventing unnecessary delays in receiving benefits.
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