Table of Contents
The DD 2870 form is a crucial document used primarily by military service members and their families to request medical care and services from the Department of Defense. This form plays a significant role in ensuring that eligible individuals receive the necessary healthcare benefits and support they are entitled to under military regulations. It encompasses various aspects, including the identification of the requester, details about the medical services needed, and the necessary authorizations for the release of medical information. Additionally, the DD 2870 form is designed to streamline the process of accessing healthcare, making it easier for service members and their dependents to navigate the complex landscape of military medical services. Understanding how to properly complete and submit this form can significantly impact the timeliness and effectiveness of care received, highlighting its importance in the overall healthcare system for military personnel.
Documents used along the form
The DD 2870 form is essential for requesting medical records and other health-related information from the Department of Defense. It is often accompanied by various other forms and documents that facilitate the process. Below is a list of commonly used forms and documents that may be relevant when submitting the DD 2870.
- DD 214: This form provides a summary of a service member's military service, including dates of service and discharge status. It is often required to verify eligibility for benefits.
- SF 180: The Standard Form 180 is used to request military records from the National Personnel Records Center. It helps in obtaining service records that may not be included in the DD 2870.
- VA Form 21-526EZ: This form is used to apply for veterans' disability compensation. It may be necessary for individuals seeking benefits related to medical conditions documented in their military records.
- California Commercial Lease Agreement: This essential document outlines the terms between landlords and business tenants, protecting both parties' interests. For more details, you can visit califroniatemplates.com.
- HIPAA Authorization Form: This document allows healthcare providers to share a patient’s medical information with specified individuals. It is crucial for ensuring compliance with privacy laws when requesting medical records.
- DD 295: The Application for the Evaluation of Educational Experiences During Military Service is used to request college credit for military training. This may be relevant for veterans seeking educational benefits.
- VA Form 10-5345: This form is used to authorize the release of medical information from the Department of Veterans Affairs. It is important for veterans needing access to their health records.
- Form 10-10EZ: This is the application for health benefits through the VA. It may be necessary for veterans to complete this form to access medical care and related services.
These forms and documents play a vital role in ensuring that requests for medical records and benefits are processed efficiently. Having the correct paperwork can significantly streamline the process for veterans and service members seeking their rights and benefits.
Other PDF Templates
How to File a No Trespassing Order - This no trespassing letter puts individuals on official notice regarding property laws.
The FedEx Release Authorization form is essential for those anticipating a delivery while being unable to receive it in person. By completing this form, recipients can specify a safe place for FedEx to leave their package, thereby preventing any delays. To streamline the process and ensure accountability, each package requires a separate form and a valid signature. If you need immediate access to this important document, download the form now to guarantee a smooth delivery experience.
Free Bol - A Straight Bill of Lading may also include references to relevant contracts or agreements.
DD 2870 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) |
|
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 |
|
|
|
|
|
|
|
|
|
|
FAQ
What is the DD 2870 form?
The DD 2870 form is a Department of Defense document used to authorize the release of medical information. It is primarily utilized by military personnel and their dependents to allow healthcare providers to share medical records with authorized individuals or entities. This form ensures that patient privacy is respected while also facilitating necessary communication regarding medical care.
Who needs to complete the DD 2870 form?
Any military service member or dependent who wishes to have their medical information shared with a third party should complete the DD 2870 form. This may include family members, healthcare providers, or legal representatives. Completing the form is essential for ensuring that the intended recipient has the legal authority to access the medical records.
How do I fill out the DD 2870 form?
Filling out the DD 2870 form involves several steps:
- Begin by entering your personal information, including your name, Social Security number, and contact details.
- Specify the individual or organization that will receive your medical information.
- Clearly outline the purpose for which the information will be used.
- Sign and date the form to confirm your consent.
Make sure to review the completed form for accuracy before submitting it to ensure that there are no delays in processing your request.
Where do I submit the completed DD 2870 form?
The completed DD 2870 form should be submitted to the appropriate healthcare provider or medical facility that holds your medical records. This could be a military treatment facility or a civilian healthcare provider, depending on where you received care. Always check with the specific facility for their submission process, as it may vary.
Is there a deadline for submitting the DD 2870 form?
While there is no strict deadline for submitting the DD 2870 form, it is advisable to do so as soon as you need your medical information shared. Delays in submitting the form may result in delays in receiving the necessary medical care or information. It’s best to plan ahead, especially if the information is needed for an upcoming appointment or legal matter.
What happens if I do not submit the DD 2870 form?
If you do not submit the DD 2870 form, your medical information will remain confidential and cannot be shared with third parties. This means that anyone who needs access to your medical records, such as a new healthcare provider or a legal representative, will not be able to obtain that information without your explicit consent. It’s important to consider the implications of not providing this authorization if you require assistance or coordination of care.
Can I revoke my authorization after submitting the DD 2870 form?
Yes, you can revoke your authorization at any time after submitting the DD 2870 form. To do so, you will need to provide a written notice to the healthcare provider or organization that received your authorization. It’s important to specify that you are revoking your previous consent. However, keep in mind that any information already shared prior to your revocation may still be used by the recipient as permitted by law.
Key takeaways
When filling out and using the DD 2870 form, there are several important points to keep in mind. This form is essential for individuals seeking to access their health records or medical information. Below are key takeaways that can help you navigate the process more smoothly.
- Understand the Purpose: The DD 2870 form is used to request access to medical records and information. Knowing its purpose will guide you in filling it out correctly.
- Provide Accurate Information: Ensure that all personal details, such as your name, Social Security number, and contact information, are filled out accurately to avoid delays.
- Signature Requirement: Remember that your signature is required on the form. This verifies your request and confirms that you have authorized the release of your medical information.
- Submission Process: After completing the form, submit it to the appropriate medical facility or agency. Check their specific submission guidelines to ensure it reaches the right department.
- Follow Up: After submission, it’s wise to follow up to confirm that your request is being processed. This can help alleviate any concerns about the status of your records.
By keeping these takeaways in mind, you can streamline the process of obtaining your medical records with the DD 2870 form.
Form Characteristics
| Fact Name | Description |
|---|---|
| Purpose | The DD 2870 form is used to authorize the release of medical information for treatment or payment purposes. |
| Who Uses It | This form is typically utilized by military personnel, veterans, and their dependents. |
| Submission | The completed form should be submitted to the appropriate healthcare provider or facility. |
| Privacy Protection | Completion of the form ensures compliance with the Health Insurance Portability and Accountability Act (HIPAA). |
| State-Specific Forms | Some states may have additional forms or requirements. Refer to state laws such as California's Confidentiality of Medical Information Act. |
| Validity Period | The authorization provided by the DD 2870 remains valid until revoked or until the specified expiration date. |