The DD 2870 form, also known as the Authorization for Disclosure of Medical or Dental Information, serves a crucial function in granting permission for the release of an individual's health records. It plays a vital role in ensuring privacy while allowing necessary medical data to be accessible when needed. For those ready to manage their medical records or facilitate their sharing, clicking the button below to fill out the form is the next step.
The administration of healthcare is filled with various forms and documents, each designed to ensure that services are delivered effectively and efficiently. Among these, the DD 2870 form plays a pivotal role, especially for military members and their families. This document is essential for those seeking to authorize the disclosure of medical or dental information to someone other than the patient. Such situations often arise when handling the intricacies of medical care coordination, insurance matters, or legal issues necessitating access to a patient's health records. While it may seem daunting at first due to its association with personal health information, understanding the form's purpose, the specifics of the information it covers, and the process of its completion and submission can significantly ease the concerns of patients and their families. It ensures that sensitive health information is shared responsibly and with the patient's consent, alleviating privacy concerns while facilitating necessary communication between healthcare providers and authorized individuals. By covering these major aspects, one can appreciate the DD 2870 form as a crucial tool in navigating the complexities of healthcare management within the military community.
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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Filling out the DD 2870 form is a necessary step for those who need to request authorization to disclose medical or dental information. The process is designed to protect privacy while allowing the necessary sharing of information. Before beginning, gather all relevant medical and personal identification information to ensure the process is smooth and accurate. There's no need to worry; by following a few simple steps, you can complete the form correctly.
By carefully following these steps, you can accurately complete the DD 2870 form, enabling the authorized exchange of medical or dental information as needed. Remember, it is essential to provide clear and correct information throughout the form to avoid delays or issues in the processing of your request.
What is a DD 2870 form?
The DD 2870 form, also known as the Authorization for Disclosure of Medical or Dental Information, is a document used by the military to authorize the release of a service member's medical or dental records to specific individuals or organizations. This form is crucial for ensuring that personal health information is shared in compliance with privacy laws, only with the consent of the service member or their legal representative.
Who needs to complete the DD 2870 form?
Any service member or their legal representative who wishes to have their medical or dental records released to someone outside of the military health system must complete the DD 2870 form. This could be for purposes such as insurance claims, continuing medical care with a civilian provider, or legal matters where health records are relevant.
How can I obtain a DD 2870 form?
The DD 2870 form is available through several channels. It can be downloaded from the Official Department of Defense (DoD) forms website or acquired directly from a military medical facility. It's always a good idea to ensure you're using the most current form by checking the issuance date on the form itself or by consulting with medical records personnel at the military medical facility.
What information is required to complete the DD 2870 form?
To fill out the DD 2870 form, the requester needs to provide detailed information including the service member's full name, DoD identification number, and specific details regarding the medical or dental information being requested. It's important to clearly specify the purpose of the request and to whom the information is to be disclosed. The form also requires the signature of the service member or their legal representative, confirming their authorization for the release of their health records.
What should I do with the form once it is completed?
Once the DD 2870 form has been accurately completed and signed, it should be submitted to the appropriate office at the military medical facility where the service member receives care. This office, often referred to as the Health Information Management or Medical Records department, will process the request and handle the disclosure of information as authorized on the form. It's recommended to keep a copy of the completed form for your records.
Filling out the DD 2870 form, also known as the Authorization for Disclosure of Medical or Dental Information form, can be challenging. Common mistakes people often make include:
By avoiding these mistakes, individuals can ensure a smoother process in requesting and receiving medical or dental information, safeguarding their privacy, and ensuring timely access to their records.
When managing or accessing healthcare information in the military, the DD Form 2870, Authorization for Disclosure of Medical or Dental Information, is frequently not the only form you might need. In navigating the complexities of military healthcare, additional forms and documents often complement the DD 2870 to ensure comprehensive care and proper handling of information. Here, we detail ten forms and documents that are commonly used alongside the DD 2870, providing a brief description of each to help streamline the process for service members, veterans, and their families.
Understanding and completing the forms mentioned above, along with the DD 2870, can be key steps in managing one's healthcare efficiently within the military system. Each form plays a vital role in ensuring that service members, veterans, and their families have access to the medical services and benefits they need, when they need them. It's important to navigate these processes with careful attention to detail to safeguard personal information and facilitate the best possible care.
The HIPAA Authorization Form is similar to the DD 2870 form, as both allow the release of individual health information. The HIPAA Authorization Form is used within civilian healthcare systems to authorize the disclosure of a person’s medical records or information. Similar to the DD 2870, it requires the patient's signature to permit the sharing of their healthcare information.
The Medical Records Release Form closely resembles the DD 2870 form in its purpose. It is used to authorize the release of medical records from one healthcare provider to another. Like the DD 2870, it is necessary when an individual wants to transfer or share their health information for reasons such as obtaining a second opinion or moving to a new healthcare provider.
The Power of Attorney for Healthcare shares similarities with the DD 2870 form. While the DD 2870 authorizes the release of specific health information, a Power of Attorney for Healthcare designates someone else to make healthcare decisions on behalf of an individual if they are unable. Both documents play significant roles in managing an individual's health care but serve different purposes within that scope.
The VA Form 10-5345, used by veterans, is akin to the DD 2870 form. The VA Form 10-5345 allows veterans to request or authorize the release of their medical records or health information managed by the Department of Veterans Affairs. This form highlights how individuals within the military and veteran communities can manage access to their health-related information.
Lastly, the Consent to Release Student Information Form, often used in educational institutions, shows similarities to the DD 2870 in its function of permitting information release. Though it is typically applied to educational records rather than health records, the essence of consent and the requirement for the individual's signature to authorize information release remain the same.
Filling out the DD 2870 form, also known as the Authorization for Disclosure of Medical or Dental Information, requires careful attention to detail to ensure accurate and compliant processing. Below are key dos and don'ts to consider:
Things You Should Do
Things You Shouldn't Do
The world of healthcare privacy and records management is nuanced and complex, especially when it comes to understanding the DD Form 2870, or Authorization for Disclosure of Medical or Dental Information. There exist several misconceptions about this form that can lead to confusion or misuse of patient information. Here, let's debunk four common misunderstandings:
The DD 2870 form is only for active-duty military personnel. It’s a common belief that the DD Form 2870 is exclusive to active-duty members. However, this form serves a broader audience, including retirees, dependents, and other individuals entitled to military healthcare benefits. It ensures that their medical or dental information can be shared according to their wishes, encompassing a wider spectrum of the military community than just those actively serving.
Submitting a DD 2870 grants unlimited access to all medical records. Many are under the impression that once signed, the DD Form 2870 gives recipients carte blanche to view all medical histories or records. In truth, the form allows for a controlled scope of disclosure. The person filling out the form can specify which parts of their medical record can be shared and with whom, allowing for privacy and discretion to be maintained.
Once completed, the DD 2870 is permanent. A common misconception is that once you submit a DD Form 2870, it’s set in stone. This isn’t the case. Individuals have the right to revoke or amend their authorization at any time. Such flexibility ensures that patients have ongoing control over their medical information and can make changes as their privacy preferences or healthcare needs evolve.
The form is self-explanatory and needs no further verification. Although the DD Form 2870 might seem straightforward, the importance of ensuring the accuracy and completeness of the information cannot be overstated. Mistakes or omissions can delay or prevent the intended sharing of information. Therefore, it’s essential for both the individual completing the form and the recipient to verify that every section is filled out correctly, and all necessary documentation is attached, to ensure the proper handling of sensitive medical or dental information.
Understanding the DD Form 2870 is crucial for anyone who needs to share medical or dental records within the military healthcare system. By dispelling these myths, individuals can more effectively manage their health information, ensuring privacy and compliance with legal standards.
The DD 2870 form, also known as the Authorization for Disclosure of Medical or Dental Information, plays a significant role in managing the sharing of personal health records within military families and the Department of Defense's healthcare system. When approaching this document, understanding its proper use and the precautions needed ensures that individuals can effectively manage their personal information. Here are some essential takeaways to consider:
Handling the DD 2870 form with care and attention ensures that individuals can confidently navigate the sharing of their health records, maintaining privacy and control over their personal information within the military healthcare system.
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