Content Overview
The DD 2870 form is an essential document for individuals seeking to access their military health records and related benefits. Designed for both service members and their families, this form plays a crucial role in ensuring that eligible individuals can obtain the necessary information to manage their healthcare effectively. It serves multiple purposes, including the authorization of the release of medical records, which can be vital for continuity of care, especially when transitioning between military and civilian healthcare systems. Understanding how to properly fill out and submit the DD 2870 can significantly streamline the process of obtaining medical documentation, thereby helping individuals avoid delays in accessing their benefits. This form not only facilitates communication between healthcare providers and patients but also reinforces the importance of maintaining accurate and up-to-date health records. As you navigate the intricacies of military healthcare, being familiar with the DD 2870 will empower you to take control of your medical information and ensure that you and your family receive the care you deserve.
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Similar forms
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SF 180 - Request Pertaining to Military Records: This form is used to request military service records, similar to the DD 2870, which is for requesting information related to medical records. Both forms facilitate access to important military documentation.
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DD Form 214 - Certificate of Release or Discharge from Active Duty: Like the DD 2870, this document provides essential information about a service member's military history. While the DD 2870 focuses on medical records, the DD Form 214 summarizes a service member's entire military service.
- New York Dirt Bike Bill of Sale: This legal document is essential for transferring ownership of a dirt bike in New York. It captures vital transaction details and ensures legality for both parties involved. You can download an editable document for your convenience.
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VA Form 21-526EZ - Application for Disability Compensation and Related Compensation Benefits: This form is similar in that it is used by veterans to request benefits related to their service. The DD 2870 is a step towards accessing medical records that may support such claims.
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HIPAA Authorization Form: This document allows individuals to authorize the release of their medical information. Similar to the DD 2870, it ensures that the necessary permissions are in place for accessing health-related records.
Document Specifics
| Fact Name | Details |
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| Purpose | The DD 2870 form is used to request a copy of a military member's medical records. |
| Who Can Use It | Active duty service members, veterans, and authorized family members can use this form. |
| Submission Method | The form can be submitted electronically or by mail to the appropriate military medical facility. |
| Privacy Protection | Personal information on the form is protected under the Health Insurance Portability and Accountability Act (HIPAA). |
| Required Information | Applicants must provide personal identification details, including Social Security number and date of birth. |
| Processing Time | It typically takes several weeks to process the request, depending on the facility's workload. |
| State-Specific Laws | In California, the form is governed by the California Confidentiality of Medical Information Act. |
| Form Updates | The DD 2870 form is periodically updated to reflect changes in military policy and regulations. |
Things You Should Know About This Form
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What is the DD 2870 form?
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is a document used by military personnel and their dependents. This form allows individuals to authorize the release of their medical or dental information to specific parties, such as healthcare providers or insurance companies. It ensures that the right people have access to important health information while maintaining patient privacy.
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Who needs to fill out the DD 2870 form?
Anyone who wishes to share their medical or dental records with another party should complete the DD 2870 form. This includes active duty service members, veterans, and eligible family members. If you are seeking treatment or need to provide information to an insurance company, this form is essential for facilitating that process.
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How do I fill out the DD 2870 form?
Filling out the DD 2870 form is straightforward. First, provide your personal information, including your name, address, and contact details. Next, specify the information you wish to disclose and to whom it will be sent. Be sure to sign and date the form to validate your authorization. It’s crucial to read the instructions carefully to ensure that all required fields are completed accurately.
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How long is the authorization valid?
The authorization granted through the DD 2870 form typically remains valid until the specified expiration date you provide or until you revoke it in writing. If no expiration date is indicated, the authorization may remain effective for one year from the date of signing. Always check with the receiving party to confirm their requirements regarding the duration of the authorization.
Documents used along the form
The DD 2870 form, known as the "Authorization for Disclosure of Medical or Dental Information," is essential for individuals seeking to authorize the release of their medical or dental records. Alongside this form, several other documents are commonly utilized to ensure a smooth process for obtaining necessary information. Below is a list of these forms and documents, each serving a specific purpose.
- DD Form 214: This document serves as a certificate of release or discharge from active duty in the military. It provides vital information regarding a service member's time in the military and is often required for accessing benefits.
- VA Form 10-5345: This form is used to request the release of medical records from the Department of Veterans Affairs (VA). It helps veterans obtain their health information for various purposes, including continuity of care.
- SF 180: The Standard Form 180 is used to request military records from the National Archives. This form is particularly important for veterans seeking copies of their service records or other related documents.
- DD Form 2875: This is the System Authorization Access Request form. It is used to request access to Department of Defense information systems, which may be necessary for managing medical or dental records.
- HIPAA Authorization Form: This form grants permission to healthcare providers to disclose a patient's health information to specific individuals or entities. It is crucial for ensuring compliance with privacy regulations.
- Arizona University Application form: The https://arizonaformpdf.com/ serves as the gateway for students seeking admission to Arizona State University, Northern Arizona University, or the University of Arizona, facilitating requests for waiving the application fee for qualifying students facing financial hardship.
- Power of Attorney: A power of attorney document allows an individual to designate another person to make decisions on their behalf. This can include decisions related to medical care and the release of medical records.
- Release of Information Form: This form is often used by healthcare providers to obtain patient consent before sharing medical records with third parties. It ensures that patient privacy is maintained while facilitating information sharing.
These documents play a vital role in the process of obtaining medical or dental information, ensuring that individuals have the necessary permissions and authorizations in place. Understanding each form's purpose can help streamline the process and protect personal information effectively.
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
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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