The DD 2870 form is a request for information used by military personnel and their families to authorize the release of medical records and information. This form ensures that individuals can access necessary health care services while maintaining privacy and security. Understanding how to properly fill out and submit the DD 2870 is crucial for anyone seeking medical documentation.
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The DD 2870 form is essential for individuals seeking to authorize the release of their medical records or information. Understanding how to fill out and use this form can streamline the process significantly.
The DD 2870 form is an important document used by the Department of Defense to authorize the release of medical records. It is often accompanied by several other forms and documents that serve various purposes in the process of obtaining medical information. Below is a list of commonly used documents that may be needed alongside the DD 2870 form.
Understanding these forms and their purposes can help streamline the process of obtaining medical records. Each document plays a vital role in ensuring that the right information is shared with the appropriate parties, ultimately aiding in the provision of necessary medical care and benefits.
The DD 2870 form, used primarily for the authorization of disclosure of medical or dental information, shares similarities with several other documents in terms of purpose and function. Below is a list of seven documents that are comparable to the DD 2870 form:
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Incomplete Information: Many individuals fail to provide all necessary details, such as their full name, social security number, or contact information. Omitting these can lead to delays in processing.
Incorrect Signature: Some people neglect to sign the form or provide a signature that does not match their printed name. This inconsistency can cause confusion and may require resubmission.
Failure to Date the Form: Not including the date when the form is completed can create issues. It is essential for tracking the timeliness of the request.
Missing Required Attachments: Individuals often forget to include necessary documents, such as proof of identity or eligibility. This oversight can result in processing delays.
Incorrect Use of Sections: Some users do not follow the instructions for filling out specific sections. Misplacing information can lead to confusion and incorrect processing.
Providing Outdated Information: Using old addresses or contact numbers can hinder communication. Keeping personal information current is vital for effective processing.
Not Reviewing the Form: Skipping the review process can lead to unnoticed errors. A careful review can catch mistakes before submission.
Neglecting Privacy Concerns: Some individuals do not consider how their personal information is shared. Understanding privacy implications is important when submitting sensitive data.
Submitting Multiple Copies: Sending in more than one copy of the form can cause confusion. It is best to submit a single, complete form to avoid complications.
Ignoring Submission Guidelines: Many overlook the specific instructions for submission, such as mailing addresses or electronic submission methods. Following guidelines is crucial for successful processing.
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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