Forms and Templates
Homepage ⇉ Free DD 2870 Template
Jump Links

The DD 2870 form plays a crucial role in the military and veteran community, serving as a vital document for individuals seeking to access their health care benefits. This form is primarily used to authorize the release of medical information, ensuring that service members and veterans can receive the necessary care without unnecessary delays. It captures essential details such as personal identification, the type of information being requested, and the purpose of the request. By facilitating communication between health care providers and patients, the DD 2870 form helps streamline the process of obtaining medical records. Additionally, it includes provisions for safeguarding personal information, thus maintaining the confidentiality of sensitive data. Understanding the importance of this form is essential for anyone navigating the complexities of military health care services.

Key takeaways

The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is an essential document for service members and their families. Here are some key takeaways to keep in mind when filling out and using this form:

  1. Purpose of the Form: The DD 2870 allows individuals to authorize the release of their medical or dental records to specified parties.
  2. Who Can Use It: Active duty service members, veterans, and eligible family members can use this form to facilitate the sharing of health information.
  3. Information Required: The form requests personal details, including name, social security number, and date of birth, to identify the individual accurately.
  4. Specify Recipients: Clearly indicate who will receive the medical or dental information. This could include healthcare providers, family members, or legal representatives.
  5. Duration of Authorization: The form allows you to specify how long the authorization remains valid. Make sure to choose a timeframe that meets your needs.
  6. Revocation Option: You have the right to revoke the authorization at any time. Ensure you understand how to do this if your circumstances change.
  7. Submit Properly: After filling out the form, submit it to the appropriate medical facility or office. Check their specific submission guidelines.
  8. Keep Copies: Always retain a copy of the completed form for your records. This can be helpful for future reference.
  9. Seek Assistance if Needed: If you have questions or need help, don't hesitate to reach out to a legal assistance office or healthcare provider.

Understanding these key points can make the process of using the DD 2870 form smoother and more efficient. Properly managing your medical information is vital for your health and wellbeing.

Dos and Don'ts

When filling out the DD 2870 form, it's essential to follow certain guidelines to ensure the process goes smoothly. Here are six things to do and avoid:

  • Do: Read the instructions carefully before starting.
  • Do: Provide accurate and complete information.
  • Do: Sign and date the form where required.
  • Do: Keep a copy of the completed form for your records.
  • Don't: Leave any required fields blank.
  • Don't: Submit the form without double-checking for errors.

Documents used along the form

The DD 2870 form is a request for access to military records and is often used in conjunction with several other forms and documents. These additional forms help streamline the process of obtaining information and ensure that all necessary permissions and identifications are in place. Below is a list of five commonly associated forms and documents.

  • DD Form 214: This document serves as a certificate of release or discharge from active duty. It provides essential information about a service member's military service, including dates of service and type of discharge.
  • SF 180: The Standard Form 180 is used to request military records from the National Archives. This form allows individuals to obtain copies of their service records and is often submitted alongside the DD 2870.
  • New York Bill of Sale: This legal document is crucial for transferring ownership of personal property, providing a record of the transaction. Resources such as Fast PDF Templates can assist in creating a tailored Bill of Sale.
  • VA Form 21-526EZ: This form is used to apply for veterans' compensation benefits. It may be required if the information requested on the DD 2870 pertains to a claim for benefits.
  • DD Form 149: This form is used to apply for a correction of military records. If there are discrepancies in the records requested via the DD 2870, this form may be necessary to rectify those issues.
  • Privacy Act Statement: This document outlines how personal information will be used and protected. It is often included with the DD 2870 to inform the individual about their rights regarding their data.

These forms and documents work together to facilitate the process of accessing military records and ensuring that individuals have the necessary information for their requests. Understanding each form's purpose can help streamline the application process and ensure compliance with regulations.

⇓ PDF Form

More PDF Documents

Doctors Prescription Pad - Utilizing the pad helps prevent prescription errors and mix-ups.

Notarized Letter of Consent for Minor to Travel - The Royal Caribbean Parental Consent form is essential for compliance with travel laws.

To ensure your benefits remain uninterrupted, it’s essential to stay informed about the renewal process for Your Texas Benefits. The texasformspdf.com/fillable-your-texas-benefits-online/ website offers convenient access to the required forms, enabling residents to easily update their information and renew their eligibility for important programs such as SNAP, TANF, and Medicaid. By utilizing these resources, families can efficiently navigate the renewal process and continue receiving the support they deserve.

Dd 214 - The DD 214 includes personal details such as the service member's name, social security number, and date of birth.

Things to Know About This Form

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 primarily by the Department of Defense. This form allows military personnel and their dependents to authorize the release of their medical or dental records to specified individuals or organizations. It ensures that sensitive health information is shared only with those who have permission, thus protecting the privacy of the service member and their family.

Who needs to fill out the DD 2870 form?

Any active duty service member, reservist, or dependent who wishes to have their medical or dental information disclosed must complete the DD 2870 form. This includes individuals seeking treatment from civilian providers or those who need to share their health records for legal, insurance, or other purposes. By filling out this form, they can designate who is authorized to access their health information.

How do I complete the DD 2870 form?

Completing the DD 2870 form involves several straightforward steps:

  1. Begin by entering the service member's personal information, including their name, Social Security number, and branch of service.
  2. Indicate the specific medical or dental records that are to be disclosed. This can include details such as dates of service or types of treatment.
  3. Designate the person or organization to whom the information will be released. This could be a family member, healthcare provider, or legal representative.
  4. Sign and date the form to confirm that you authorize the release of your information.

It is important to ensure that all information is accurate and complete to avoid delays in processing.

Where do I submit the DD 2870 form?

After completing the DD 2870 form, submission should be directed to the appropriate medical or dental facility where the service member receives care. Each facility may have specific instructions regarding submission, so it is advisable to check with them directly. Some facilities may allow electronic submission, while others may require a physical copy to be delivered in person or via mail.

What happens after I submit the DD 2870 form?

Once the DD 2870 form is submitted, the designated facility will process the request for the release of medical or dental information. The time it takes to fulfill the request can vary based on several factors, including the facility's workload and the complexity of the request. Typically, the individual who requested the disclosure will be notified once the information has been released. It is important to keep in mind that the authorization granted through this form remains valid until it is revoked or until a specified expiration date, if one is provided.

Preview - DD 2870 Form

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

 

 

 

 

 

 

 

 

Document Specifics

Fact Name Description
Purpose The DD Form 2870 is used to request access to military medical records and health information.
Eligibility Eligible individuals include military personnel, veterans, and authorized family members.
Submission Process The completed form must be submitted to the appropriate military health system facility or records office.
Privacy Act Compliance This form is governed by the Privacy Act of 1974, ensuring the protection of personal information.
State-Specific Forms Some states may have additional requirements or forms for accessing health records, governed by state health privacy laws.

How to Fill Out DD 2870

Completing the DD 2870 form is a straightforward process. After filling out the form, you will need to submit it according to the specific instructions provided for your situation. Ensure that all required fields are filled out accurately to avoid delays in processing.

  1. Begin by downloading the DD 2870 form from a reliable source.
  2. Read the instructions on the form carefully before starting to fill it out.
  3. In the first section, enter your personal information, including your name, address, and contact details.
  4. Provide your Social Security Number and date of birth in the designated fields.
  5. In the next section, indicate your relationship to the service member or veteran.
  6. Complete the information regarding the service member or veteran, including their name and service details.
  7. Fill out the specific information requested about the claim or request you are making.
  8. Review all the information for accuracy and completeness.
  9. Sign and date the form at the bottom where indicated.
  10. Make a copy of the completed form for your records before submitting it.
  11. Submit the form as directed, either by mail or electronically, depending on the requirements.