Table of Contents
The DD 2870 form is an essential document utilized primarily in the United States military and various branches of the Department of Defense. It serves as the "Authorization for Disclosure of Medical or Dental Information," allowing service members and veterans to grant permission for their medical information to be shared with specific individuals or entities. The completion of this form is often necessary for obtaining medical treatment, transferring care, or even accessing disability benefits. Military personnel may use the DD 2870 to authorize the release of their medical records to healthcare providers, family members, or legal representatives. Understanding the proper use of this form is crucial, as it helps protect an individual's privacy while ensuring that necessary information is accessible for care and support. Additionally, specific instructions regarding the completion of the form, the parties involved, and the duration of the authorization are critical components that individuals must consider before submission. Compliance with the guidelines outlined in the DD 2870 form ensures that all parties respect the confidentiality of the service member's health information, aligning with both military regulations and privacy laws.
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) |
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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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File Breakdown
| Fact Name | Description |
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| Purpose | The DD 2870 form is used to request access to a service member's military medical records and information from the Department of Defense. |
| Eligibility | Eligible individuals include service members, their authorized representatives, or legally-designated representatives. |
| Governing Regulations | The use of the DD 2870 form is governed by the Freedom of Information Act (FOIA) and Department of Defense (DoD) regulations. |
| Submission Process | After completing the form, it must be submitted to the appropriate military branch's records custodian. |
| Processing Time | Requests typically take 10 to 20 business days for processing, but may vary depending on the volume of requests. |
Guide to Using DD 2870
The DD 2870 form is a vital document in certain military processes. After completion, the form needs to be submitted to the appropriate authorities for processing. This submission may lead to access to services or benefits as indicated by the form's purpose.
- Obtain a copy of the DD 2870 form. This can typically be downloaded from the official military or government website.
- Read the instructions carefully to understand the requirements for completion.
- Begin by filling in the personal information section. Provide your full name, social security number, and contact information.
- Complete the section regarding your military affiliation. Indicate your branch of service and your current duty status.
- Fill in any required information about the specific request or service you are seeking. This may include details such as dates or locations relevant to the request.
- Review your entries to ensure all information is accurate and complete. Accuracy is important to avoid delays.
- Sign and date the form at the designated place to certify your information is true.
- Submit the completed form according to the instructions provided. Keep a copy for your records.
Get Answers on DD 2870
What is the DD 2870 form?
The DD 2870 form is a document used by military service members, their families, and eligible beneficiaries to authorize the release of medical information. It ensures that individuals consent to have their medical records shared as necessary for their care and administrative purposes.
Who needs to fill out the DD 2870 form?
This form is typically completed by service members or their authorized representatives when they need to allow healthcare providers or other entities access to their medical information. It's particularly relevant during transitions between healthcare systems or in legal situations involving medical records.
What information is required on the DD 2870 form?
The DD 2870 form requests various pieces of information, including:
- Full name of the service member or beneficiary
- Social Security number or identification number
- Contact information for both the individual requesting the information and the recipient
- Details regarding the type of information being requested
- Date and signature of the individual providing consent
How is the DD 2870 form submitted?
Once completed, the DD 2870 form should be submitted to the appropriate medical facility or organization that will process the request. It may require either physical delivery or electronic submission, depending on the facility's protocols.
Can the DD 2870 form be revoked?
Yes, individuals have the right to revoke their consent at any time. To do this, a written notice of revocation should be provided to the organization that received the original consent. It is important to include identifying information to ensure the correct record is updated.
How long does the authorization last?
The authorization provided by the DD 2870 form remains valid until it is revoked or until the specific time frame indicated in the document expires. Individuals should review and update their authorization as necessary to reflect their current preferences.
Where can I find the DD 2870 form?
The DD 2870 form can typically be found on official military or government websites. It is recommended to visit the Defense Health Agency or similar resources where military-related documents are hosted to download and print the form.
Common mistakes
Filling out the DD 2870 form can be a straightforward process, but there are common errors that individuals may encounter. One mistake often seen is the failure to provide accurate personal information. This includes not entering the correct Social Security number or misrepresenting addresses. Such inaccuracies can lead to complications down the line, resulting in delays and possibly affecting benefits.
Another frequent mistake is not signing the form. Without a signature, the form is incomplete and cannot be processed. Many people forget this step, especially if they are in a rush to submit their paperwork. Ensuring that all required signatures are included is crucial for timely handling of the application.
Some applicants neglect to check the instructions carefully. The DD 2870 comes with specific guidelines on how to fill it out, including which documents or additional information may be required. Ignoring these instructions can lead to omitted information, which might result in the form being returned or denied.
Providing insufficient detail in the sections that require explanations is another common misstep. Applicants sometimes write vague answers or leave portions blank when prompted for thorough explanations. Offering comprehensive, clear responses helps the reviewing agency fully understand the applicant's situation.
Moreover, individuals often fail to double-check for typos or formatting issues before submission. Small errors, like misspellings of names or incorrect dates, can create confusion and hinder the processing of the form. Taking the time to proofread can prevent these easily avoidable mistakes.
Lastly, individuals may overlook the submission deadline. Each application has a specific timeline in which it must be submitted. Missing this deadline can result in the loss of benefits or additional complications. Being aware of and adhering to deadlines is essential for the successful completion of the process.
Documents used along the form
The DD 2870 form, officially known as the "Authorization for Disclosure of Medical or Dental Information," facilitates the release of medical information by the U.S. Department of Defense. When submitting this form, individuals may need to accompany it with several other documents to ensure a comprehensive application. Below is a list of related forms and documents often used in conjunction with the DD 2870 form, along with brief descriptions of each. These documents help streamline processes and clarify requests for medical or dental information.
- DD 214: The Certificate of Release or Discharge from Active Duty provides evidence of service in the armed forces, often needed to access certain benefits and information.
- VA Form 10-5345: Used to request information from Veterans Affairs, this form is essential for veterans seeking their medical records from VA facilities.
- SF 180: The Request Pertaining to Military Records allows individuals to request all kinds of military records, including medical records, from the National Archives.
- DD Form 2005: This form is used to authorize the release of patient information specifically for non-military healthcare providers when seeking medical or dental information.
- DD Form 2870-1: Often used in conjunction with the DD 2870, this form provides additional clarification for the purpose of the requested information.
- Power of Attorney (POA): This legal document may be required if someone is acting on behalf of another individual to request their medical records.
- CAARNG Form 1003: For members of the California Army National Guard, this form is used to authorize access to medical records maintained by the National Guard.
- Health Information Release Form: Specific to certain medical facilities, this form allows for the disclosure of health information to third parties.
- TOE Form 285: This form is typically required for those requesting records related to their participation in training or operational exercises involving military medical services.
- Patient Privacy Rights Notice: This document informs individuals about their rights regarding their medical information under federal law. It is often included when requesting disclosures.
Completing and submitting the DD 2870 form alongside these associated documents can facilitate a smoother process in obtaining relevant medical or dental information. Whether you are a veteran, a family member, or a legal representative, understanding these forms ensures that you can navigate the system effectively.
Similar forms
The DD 2870 form is a widely used document within the military context, particularly for those seeking to access their medical records or related health information. Several other documents serve a similar purpose in facilitating access to sensitive information or conveying consent. Below are four documents that share similarities with the DD 2870 form:
- HIPAA Authorization Form: This form allows individuals to grant permission for healthcare providers to disclose their medical information to designated parties. Like the DD 2870, it focuses on authorizing the release of personal health information.
- Standard Form 180 (SF-180): Used by veterans to request copies of military records, this form enables individuals to access their own historical data. The SF-180 functions similarly to the DD 2870 in terms of facilitating requests for vital information.
- VA Form 21-4142: This form is utilized by veterans to authorize the release of private medical records. It specifically entails granting permission for the Veterans Affairs office to obtain necessary health records, just as the DD 2870 pertains to accessing medical information.
- Request for Medical Records Release: This general request form can be used in various healthcare settings to allow providers to share an individual's medical records with others. This document shares the same core principle of ensuring patient consent for the release of sensitive health information, akin to the objective of the DD 2870.
Dos and Don'ts
When filling out the DD 2870 form, it is important to follow certain guidelines to ensure accuracy and efficiency. Here are seven things to do and not to do:
- Do: Read the instructions carefully before starting to fill out the form.
- Do: Use clear and legible handwriting or type the information if possible.
- Do: Double-check all information for accuracy before submitting.
- Do: Provide all required documentation as outlined in the instructions.
- Don't: Skip any sections of the form, even if they seem unnecessary.
- Don't: Submit the form without completing all required fields.
- Don't: Forget to keep a copy of the submitted form for your records.
Misconceptions
The DD 2870 form, known as the "Authorization for Disclosure of Medical or Dental Information," often leads to misunderstandings. Here are nine common misconceptions regarding this important document.
- It's only for service members. Many people believe the DD 2870 form can only be filled out by active duty personnel. However, it is applicable to both active duty and retired service members, as well as their dependents.
- It is only for medical information. While the form is primarily used for medical records, it can also be utilized for dental information. This includes any records relevant to dental care provided to the person named on the form.
- All healthcare providers use the DD 2870. Not all healthcare providers will require this specific form. Some may have their own version or other processes in place for authorizing the release of medical information.
- Filling it out is complicated. Completing the DD 2870 form is quite straightforward. It typically requires basic personal information and details about the medical records needed, making it easier than some might think.
- Once submitted, it cannot be revoked. After submitting the DD 2870 form, the individual has the right to revoke it at any time. This can usually be done through a written statement, provided it is submitted to the relevant healthcare provider.
- It guarantees the release of all records. Submission of the form does not ensure that all requested records will be released. The healthcare provider will still review the request according to legal and policy guidelines to determine what can be shared.
- Personal information is not protected. Many individuals believe that sensitive personal information might be compromised when the DD 2870 is used. In reality, the form is designed to protect your privacy and ensure your information is handled securely.
- It can be filed anytime without limitations. There may be specific timelines and guidelines regarding when the form can be requested and used. Understanding these limitations is crucial to ensure that the request is valid.
- It's a one-time use form. The DD 2870 can serve multiple purposes. You can use it for various requests as long as it meets the healthcare provider's requirements and is properly completed each time.
Being aware of these misconceptions can help alleviate concerns and ensure that the DD 2870 form is used correctly and effectively when needed.
Key takeaways
The DD 2870 form is essential for requesting military health care benefits and services. Here are some key takeaways to help you navigate filling it out and using it effectively.
- Purpose: The DD 2870 form is used by individuals to authorize the release of medical information and to request health care benefits through the military.
- Who Can Use It?: This form can be utilized by active duty service members, veterans, and eligible family members seeking access to medical services.
- Personal Information: Ensure that all sections requiring personal information—such as name, social security number, and address—are filled out accurately to avoid processing delays.
- Signature Requirements: The form must be signed by the individual requesting services. A signature confirms understanding and agreement with the terms outlined.
- Submission Process: Submit the completed DD 2870 form to the designated health care facility or organization as instructed. This may vary based on your branch of the military.
- Keeping Copies: It's wise to keep a copy of the filled-out form for your records. This could be useful if there are any questions or issues regarding your request later.
- Follow-Up: If you don’t receive confirmation after submission, follow up with the appropriate facility to ensure your request is being processed.
- Updating Information: Should any of your personal information change after submitting the form, notify the facility as soon as possible to keep your records current.
- Privacy Considerations: Be mindful of the information you share, as this form involves sensitive personal and health information. Use secure methods when sending forms that contain this data.
Understanding these key elements of the DD 2870 form can streamline your experience in accessing military health care benefits.
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