Content Overview
The DD 2870 form plays a crucial role in the military and veteran community, serving as a vital document for individuals seeking to access certain benefits and services. This form is primarily used to authorize the release of medical information, ensuring that healthcare providers can share necessary details with authorized personnel or agencies. By completing the DD 2870, service members and veterans grant permission for their medical records to be disclosed, which can be essential for receiving proper care and support. Additionally, the form helps streamline the process of obtaining benefits, as it allows for the verification of medical history when applying for services through the Department of Veterans Affairs or other related organizations. Understanding the importance of the DD 2870 is key for those navigating the complexities of military healthcare and benefits, as it ensures that medical information is handled securely and efficiently.
Key takeaways
The DD 2870 form is an important document used by service members and their families to authorize the release of medical information. Understanding how to fill it out correctly can streamline processes and ensure privacy. Here are some key takeaways:
- Accurate Information: Ensure that all personal details, including name, Social Security number, and contact information, are filled out accurately to avoid delays.
- Signature Requirement: The form must be signed by the individual authorizing the release of information. A missing signature can render the form invalid.
- Specificity Matters: Clearly indicate the specific information you wish to be released. Vague requests may lead to incomplete information being provided.
- Understand the Purpose: Familiarize yourself with why the information is needed. This understanding can help you determine what to include on the form.
- Keep Copies: Always retain a copy of the completed DD 2870 form for your records. This can be useful for future reference or if any issues arise.
By following these guidelines, individuals can ensure that their use of the DD 2870 form is efficient and effective.
Guide to Writing DD 2870
After you have gathered the necessary information, the next step involves filling out the DD 2870 form accurately. This form is essential for ensuring that your request is processed efficiently. Take your time and ensure that all information is correct before submission.
- Begin by downloading the DD 2870 form from the official website or obtaining a hard copy from the appropriate office.
- At the top of the form, fill in your personal information, including your full name, address, and contact details.
- Provide your Social Security Number (SSN) or other identification numbers as required.
- Indicate your relationship to the service member or veteran, if applicable.
- Complete the section regarding the purpose of the request. Be clear and concise in your explanation.
- Sign and date the form at the designated area to validate your request.
- Review the entire form for accuracy and completeness. Make any necessary corrections.
- Submit the completed form according to the instructions provided, either by mail or electronically as specified.
Following these steps will help ensure that your form is filled out correctly and submitted without delay. If you have any questions or need assistance, consider reaching out to the appropriate office for guidance.
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Form Preview 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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Documents used along the form
The DD 2870 form is an important document used primarily for requesting medical records within the military. However, it is often accompanied by other forms and documents that help streamline the process or provide additional necessary information. Here’s a list of related forms that you may encounter.
- DD Form 214: This form provides a summary of a service member’s military service. It includes information such as dates of service, discharge status, and awards received. It is often required for veterans seeking benefits.
- SF 180: The Standard Form 180 is used to request military records from the National Archives. This form is particularly useful for veterans who need to obtain their service records or medical files.
- VA Form 21-526EZ: This is the application for disability compensation and related benefits from the Department of Veterans Affairs. It’s essential for veterans seeking financial assistance due to service-related injuries or conditions.
- VA Form 10-5345: This form is used to request the release of medical records from the VA. It allows veterans to authorize the VA to share their health information with other healthcare providers.
- DD Form 2796: The Post-Deployment Health Assessment is completed by service members returning from deployment. It helps identify any health concerns that may have arisen during service.
- DD Form 2900: This is the Post-Deployment Health Reassessment form. It is used to follow up on health concerns after a service member has returned home, ensuring ongoing care and support.
- VA Form 21-4142: This form is used to authorize the release of private medical records. It is often necessary when veterans need to provide additional medical evidence to support their claims.
- New York Boat Bill of Sale Form: To ensure safe transactions, utilize the essential Boat Bill of Sale form resources for clear documentation of your boat sales.
- SF 50: The Notification of Personnel Action is used to document changes in a service member's employment status. It may be required for benefits applications or other administrative processes.
- DD Form 149: This form is used to apply for a correction of military records. It can be helpful for veterans who need to amend their service records for various reasons.
Understanding these forms can significantly ease the process of obtaining medical records and accessing benefits. Each form serves a unique purpose and can provide essential information for veterans and service members navigating their rights and entitlements.