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The DD 2870 form plays a crucial role in the military and veteran communities, serving as a vital tool for those seeking to access their medical records and other health-related information. This form is primarily used to authorize the release of personal health information, ensuring that service members and veterans can obtain the necessary documentation for their medical care. By completing the DD 2870, individuals grant permission for healthcare providers to share their medical records with specified entities, which may include family members, legal representatives, or other healthcare professionals. The form is straightforward, requiring essential details such as the individual’s personal information, the purpose of the request, and the specific records needed. Understanding the importance of the DD 2870 is essential for anyone navigating the complexities of military healthcare, as it facilitates access to critical information that can significantly impact a person's health and well-being.

DD 2870 Preview

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

 

 

 

 

Reset

 

 

 

 

 

 

 

 

Common mistakes

The DD 2870 form is essential for individuals seeking to authorize the release of their medical records. However, mistakes during the completion of this form can lead to delays or denials. Here are nine common errors people make when filling out the DD 2870 form:

  1. Inaccurate Personal Information: Failing to provide correct name, address, or Social Security number can result in processing issues.

  2. Missing Signatures: Not signing the form or forgetting to date it can render the authorization invalid.

  3. Incorrect Recipient Information: Listing the wrong entity or person as the recipient of the medical records can lead to unauthorized disclosures.

  4. Insufficient Details on Purpose: Not clearly stating the purpose for which the records are requested may cause confusion and delays.

  5. Failure to Specify Records: Not indicating which specific medical records are needed can result in receiving irrelevant information.

  6. Omitting Expiration Date: Forgetting to include an expiration date for the authorization can lead to uncertainty about the validity period.

  7. Not Reviewing for Completeness: Skipping a final review of the form for completeness can lead to overlooked errors.

  8. Ignoring Privacy Concerns: Not understanding the implications of sharing personal health information can lead to privacy violations.

  9. Submitting Without a Copy: Failing to keep a copy of the submitted form for personal records can create challenges in tracking the authorization.

By avoiding these common mistakes, individuals can ensure a smoother process when requesting their medical records through the DD 2870 form.

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Dos and Don'ts

When filling out the DD 2870 form, it's important to follow certain guidelines to ensure accuracy and efficiency. Here are some things you should and shouldn't do:

  • Do read the instructions carefully before starting.
  • Do provide accurate and complete information.
  • Do double-check your entries for any errors.
  • Do sign and date the form where required.
  • Don't leave any required fields blank.
  • Don't use abbreviations unless specified.
  • Don't submit the form without reviewing it.
  • Don't forget to keep a copy for your records.

Misconceptions

The DD 2870 form is often misunderstood. Here are six common misconceptions about this form:

  1. It is only for active-duty military members.

    Many believe that only active-duty personnel need to fill out the DD 2870. In reality, this form can also apply to veterans and eligible family members seeking benefits.

  2. It is a complicated form.

    Some think the DD 2870 is difficult to understand. However, the form is straightforward and designed to be user-friendly, making it easier for applicants to complete.

  3. Submitting the form guarantees benefits.

    Filling out the DD 2870 does not automatically ensure that benefits will be granted. The form is just one step in the application process, and eligibility will still be evaluated.

  4. It can only be submitted by mail.

    Many assume that the DD 2870 must be mailed in. In fact, electronic submissions are often accepted, providing a quicker way to process applications.

  5. It is only needed once.

    Some people think they only need to fill out the DD 2870 a single time. Depending on the situation, updates or resubmissions may be required, especially if personal information changes.

  6. All sections must be completed for submission.

    While it is important to provide as much information as possible, not every section is mandatory. Applicants should focus on the relevant sections that apply to their situation.

Understanding these misconceptions can help individuals navigate the process more effectively and ensure they receive the benefits they deserve.

Detailed Guide for Using DD 2870

Once you have the DD 2870 form in hand, it’s important to fill it out accurately to ensure your request is processed smoothly. Follow these steps carefully to complete the form.

  1. Begin by entering your personal information in the designated fields. This includes your full name, Social Security number, and contact details.
  2. Provide information about your relationship to the service member, if applicable. This helps clarify your eligibility for the requested information.
  3. Fill in the details of the service member, including their name and Social Security number. Make sure this information is correct to avoid any delays.
  4. Indicate the purpose of your request. Clearly state why you need the information, as this can help expedite the process.
  5. Sign and date the form at the bottom. Your signature is essential, as it confirms that the information provided is accurate and that you understand the implications of your request.
  6. Review the completed form for any errors or missing information. Double-checking can save time and prevent complications.
  7. Submit the form according to the instructions provided, whether by mail or electronically. Ensure you keep a copy for your records.

After submitting the form, you may need to wait for a response. Be patient, as processing times can vary based on the nature of the request and the workload of the office handling it.