The DD 2870 form is a document used by military personnel and their families to authorize the release of medical information. This form ensures that healthcare providers can share necessary medical records with designated individuals. Understanding how to properly fill out the DD 2870 is crucial for maintaining privacy and ensuring access to important health information.
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The DD 2870 form is essential for individuals seeking to request medical records from the Department of Defense. Here are some key takeaways to consider when filling out and using this form:
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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The DD 2870 form is similar to the Standard Form 180 (SF 180), which is used to request military records. Both forms serve as official requests for information but differ in their specific purposes. While the SF 180 focuses on obtaining copies of a veteran's service records, the DD 2870 is primarily used to authorize the release of medical records. Each form requires the requester to provide personal information and details about the records sought, ensuring the request is processed efficiently.
Another comparable document is the VA Form 21-4142, which is used to authorize the release of medical information to the Department of Veterans Affairs. Like the DD 2870, this form requires the individual to grant permission for the release of their health records. However, the VA Form 21-4142 is specifically tailored for claims processing, whereas the DD 2870 is more general and can be used in various contexts related to military health care.
The Privacy Act Release Form is also akin to the DD 2870. This document allows individuals to authorize the release of their personal information held by federal agencies. Both forms emphasize the importance of privacy and consent, ensuring that sensitive information is shared only with authorized parties. The key difference lies in the scope of use; the Privacy Act Release Form applies broadly across government agencies, while the DD 2870 is specific to military health records.
The Medical Records Release Authorization form is another document that shares similarities with the DD 2870. This form is used by healthcare providers to obtain permission from patients to release their medical records. Both forms require clear consent from the individual, ensuring that health information is not disclosed without permission. However, the Medical Records Release Authorization is typically used in civilian healthcare settings, while the DD 2870 is specifically for military-related medical records.
The HIPAA Authorization Form is relevant as well. This form allows individuals to authorize healthcare providers to share their medical information in compliance with the Health Insurance Portability and Accountability Act. Similar to the DD 2870, it requires explicit consent from the individual for the release of health information. The primary distinction is that the HIPAA Authorization Form is used in various healthcare contexts, while the DD 2870 is focused on military medical records.
The Form 10-5345 is another document that aligns with the DD 2870. This form is used by veterans to request access to their medical records from the VA. Both forms facilitate the release of health information, but the Form 10-5345 is specifically designed for veterans seeking records from the VA, while the DD 2870 can be used for broader military health record requests.
The Authorization for Release of Information form used by many hospitals and clinics is also similar. This document allows patients to authorize the release of their medical records to designated individuals or entities. Both forms require the individual’s consent and personal information to process the request. However, the hospital-specific form is often used in civilian healthcare, while the DD 2870 is tailored for military records.
The Form 21-526EZ, used for disability compensation claims, is another related document. This form allows veterans to apply for benefits and includes sections where veterans can authorize the release of their medical records. While both forms involve consent for record release, the Form 21-526EZ is primarily focused on initiating claims for benefits, whereas the DD 2870 is strictly about authorizing medical record access.
In Maryland, when transferring ownership of a motor vehicle, it's essential to use the Maryland Motor Vehicle Bill of Sale form, which acts as a legal record of the transaction. To facilitate this process, you can find helpful resources, including Vehicle Bill of Sale Forms, that guide you through filling out the necessary documentation accurately, ensuring compliance with state regulations.
The Authorization for Release of Medical Records form used by insurance companies is also comparable. This document allows policyholders to authorize their healthcare providers to share medical information with the insurance company. Both forms require the individual’s consent for the release of health information, but the insurance form is specific to the insurance context, while the DD 2870 is specific to military medical records.
Lastly, the Form 5-10-10, used by the Department of Defense for medical record requests, shares similarities with the DD 2870. Both forms require individuals to provide consent for the release of their medical information. The Form 5-10-10 is more focused on specific medical record requests within the DoD system, while the DD 2870 serves a broader purpose in authorizing the release of military health records.
After obtaining the DD 2870 form, you will need to complete it accurately to ensure proper processing. Follow these steps carefully to fill out the form correctly.
Once you have completed the form, it will need to be submitted to the appropriate office for processing. Ensure that you keep a copy for your records.
The DD 2870 form is an essential document used within the military to authorize the release of medical records and information. When dealing with medical care or benefits, several other forms and documents may be needed to ensure a smooth process. Below is a list of common forms that are often used alongside the DD 2870, each serving a specific purpose.
Understanding these documents can help service members and their families navigate the complexities of military benefits and services. Each form plays a critical role in ensuring that individuals receive the support and resources they deserve.
Incomplete Information: Many individuals fail to provide all required fields, leading to delays in processing. Every section of the form must be filled out accurately.
Incorrect Personal Details: Errors in names, Social Security numbers, or dates of birth can cause significant issues. Double-checking this information is crucial.
Failure to Sign: Some people overlook the necessity of signing the form. Without a signature, the form is not valid.
Missing Supporting Documents: Not including required documentation can result in a rejection of the application. Be sure to attach all necessary paperwork.
Not Following Submission Guidelines: Submitting the form to the wrong address or in the wrong format can lead to delays. Always verify the submission instructions.
Ignoring Deadlines: Some individuals miss crucial deadlines for submission. It is important to be aware of and adhere to any timelines provided.
Inadequate Review: Skipping a final review of the completed form can lead to overlooked mistakes. Taking a moment to review can save time later.
Assuming All Forms Are the Same: Each form has specific requirements and should not be treated interchangeably. Familiarize yourself with the DD 2870's unique aspects.
Not Seeking Help When Needed: Some individuals hesitate to ask for assistance or clarification. Utilizing available resources can prevent errors and confusion.
When filling out the DD 2870 form, it's important to follow certain guidelines to ensure accuracy and compliance. Here’s a helpful list of things to do and avoid: