DD 2870 PDF Template

DD 2870 PDF Template

The DD 2870 form is a document used by military personnel and their families to request dental care benefits. It serves as an essential tool in ensuring that eligible individuals receive the necessary dental services. To get started on your application, fill out the form by clicking the button below.

Article Guide

The DD 2870 form is an essential document used primarily by individuals seeking to authorize the release of their medical records within the context of military service. This form plays a crucial role in ensuring that service members can access necessary medical information for various purposes, including treatment continuity and benefits eligibility. By completing the DD 2870, individuals grant permission for healthcare providers to share their medical history with designated parties, which may include other healthcare professionals or organizations involved in their care. Additionally, the form includes sections for the service member to specify the duration of the authorization and the scope of the information to be released. Understanding the implications of this form is vital for service members and their families, as it directly affects their healthcare access and management. Properly completing the DD 2870 can help streamline the process of obtaining medical records, ultimately supporting better health outcomes and continuity of care for those who have served in the military.

DD 2870 Preview

Prescribed by: DoDM 6025.18

CUI (when filled in)

(Updated 20231219)

AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION

PRIVACY ACT STATEMENT

AUTHORITY: Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C. Chapter 55, Medical and Dental Care; DoD Manual (DoDM) 6025.18, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs; and E.O. 9397 (SSN).

PRINCIPAL PURPOSE(S): DD Form 2870 collects patient data and a patient’s, or their parent’s or legal representative’s, authorization for a military treatment facility or dental treatment facility or DoD health plan to use or disclose an individual’s protected health information.

ROUTINE USE(S): To third parties or individuals as per your written authorization.

APPLICABLE SORN: EDHA 07, Military Health Information System (June 15, 2020; 85 FR 36190). https://dpcld.defense.gov/Portals/49/Documents/

Privacy/SORNs/DHA/EDHA-07.pdf

DISCLOSURE: Voluntary. If you choose not to provide your information, no penalty may be imposed and there will be a non-release of the protected health information. This form will not be used for authorization to disclose substance abuse information or treatment, if any, within your medical records nor will it be used to authorize the use or disclosure of psychotherapy notes, if any, within your medical records.

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)

 

 

 

 

 

BOTH

INPATIENT

OUTPATIENT

 

 

 

 

 

 

 

 

 

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, NOV 2023

CUI (when filled in)

Controlled by: DHA

 

Reset

PREVIOUS EDITION IS OBSOLETE.

 

CUI Category: PRVCY

 

Distribution/Dissemination Control: FEDCON

 

 

 

POC: dha.ncr.bus-ops.mbx.dha-formsmanagement@health.mil

↓ DD 2870

File Properties

Fact Name Description
Purpose The DD 2870 form is used to authorize the release of medical information for military personnel and their dependents.
Eligibility Active duty service members, reservists, and their family members can use this form to grant access to their health records.
Confidentiality Information provided through the DD 2870 is protected under the Health Insurance Portability and Accountability Act (HIPAA).
State-Specific Forms Some states may have their own forms for medical record release, governed by state laws such as California's Civil Code Section 56.10.
Submission Process The completed DD 2870 form should be submitted to the appropriate medical facility or health care provider.
Validity The authorization granted by the DD 2870 remains valid until revoked or until a specified expiration date is reached.

Instructions on Utilizing DD 2870

After obtaining the DD 2870 form, the next step involves accurately filling it out. This process requires careful attention to detail to ensure all necessary information is provided. Once completed, the form can be submitted as per the instructions provided by the relevant authority.

  1. Begin by downloading or printing the DD 2870 form from the official source.
  2. At the top of the form, enter your personal information, including your full name, address, and contact details.
  3. Provide your Social Security Number (SSN) in the designated space.
  4. Indicate your relationship to the service member, if applicable.
  5. Fill out the sections related to the specific purpose for which the form is being completed.
  6. Review all entries for accuracy and completeness.
  7. Sign and date the form at the bottom where indicated.
  8. Make a copy of the completed form for your records.
  9. Submit the form according to the instructions provided, whether electronically or by mail.

Important Facts about DD 2870

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 the Department of Defense. It allows military personnel and their dependents to authorize the release of their medical or dental records to specified individuals or organizations. This form is essential for ensuring that medical information is shared appropriately and only with those who have permission to access it.

Who needs to fill out the DD 2870 form?

Any service member or eligible dependent who wishes to share their medical or dental information with another party must complete the DD 2870 form. This could include situations where a patient wants to allow a family member, a healthcare provider, or a legal representative to access their records. Filling out this form ensures that the release of information complies with privacy regulations.

How do I complete the DD 2870 form?

Completing the DD 2870 form is straightforward. Begin by providing your personal information, including your name, Social Security number, and contact details. Next, specify the individual or organization you are authorizing to receive your medical or dental information. Be sure to indicate the purpose of the disclosure and the type of information being released. Finally, sign and date the form to validate your authorization.

Where do I submit the DD 2870 form?

After filling out the DD 2870 form, submit it to the appropriate medical facility or dental clinic that holds your records. Each facility may have its own procedures for processing these requests, so it’s a good idea to check with them for any specific submission guidelines. You may be able to submit the form in person, by mail, or electronically, depending on the facility's policies.

Is there a fee for using the DD 2870 form?

Generally, there is no fee associated with completing and submitting the DD 2870 form for the release of your own medical or dental records. However, if you request copies of your records, some facilities may charge a fee for duplication or processing. It’s best to inquire about any potential costs when you submit your form.

How long does it take to process the DD 2870 form?

The processing time for the DD 2870 form can vary depending on the facility and the volume of requests they receive. Typically, it may take anywhere from a few days to a couple of weeks to process your request. If you need your records urgently, communicate your needs to the facility, as they may be able to expedite the process for you.

Common mistakes

Filling out the DD 2870 form can be a straightforward process, but many people make common mistakes that can lead to delays or complications. One frequent error is not providing complete personal information. The form requires specific details, including your full name, Social Security number, and contact information. Omitting any of this information can result in processing issues.

Another common mistake is failing to sign and date the form. This step may seem minor, but without a signature, the form is not valid. Always double-check that you’ve signed and dated the form before submitting it. This simple oversight can cause significant delays in your application process.

Many individuals also overlook the importance of reading the instructions carefully. Each section of the DD 2870 form has specific requirements. Ignoring these instructions can lead to incomplete or inaccurate submissions. Take the time to understand what is required for each part of the form.

In addition, some people forget to include necessary supporting documents. The DD 2870 may require additional paperwork, such as identification or other verification documents. Failing to attach these can result in your application being returned or denied.

Lastly, individuals often do not keep a copy of the completed form. Having a copy is crucial for your records. If any issues arise, you’ll want to refer back to what you submitted. Keeping a copy can save you time and trouble in the long run.

Documents used along the form

The DD 2870 form is a critical document used in various military and veteran contexts, particularly for the release of medical information. However, several other forms and documents often accompany it to ensure comprehensive processing of requests. Below is a list of these related documents, each serving a specific purpose.

  • 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. It allows veterans to obtain copies of their service records, which can be crucial for various benefits and claims.
  • VA Form 21-526EZ: This is the application for disability compensation and related compensation benefits. Veterans use it to apply for financial support due to service-related injuries or conditions.
  • VA Form 10-5345: This form is used to request the release of medical records from the Department of Veterans Affairs. It is essential for veterans seeking to share their health information for various purposes.
  • DD Form 2875: This form is used to request access to the Defense Information System for Security (DISS). It is important for individuals needing access to sensitive information related to security clearances.
  • VA Form 21-4142: This is the authorization to disclose information to the Department of Veterans Affairs. It allows veterans to permit third parties to share their medical information with the VA.
  • DD Form 149: This form is used to apply for a correction of military records. It helps service members or veterans correct any errors in their official military documentation.
  • VA Form 21-8940: This application is for increased compensation based on unemployability. Veterans use it to claim benefits when they are unable to work due to service-connected disabilities.
  • VA Form 21-4138: This is a statement in support of claim. Veterans use it to provide additional evidence or information to support their claims for benefits.

Each of these documents plays a vital role in the processes surrounding military service and veteran benefits. Understanding their functions can help individuals navigate the complexities of military and veteran affairs more effectively.

Similar forms

The DD 2870 form is a crucial document used primarily in the military context to authorize the release of medical records. Here are seven documents that are similar to the DD 2870 form, highlighting their similarities:

  • SF 180 (Request Pertaining to Military Records): This form allows individuals to request their military service records, similar to how the DD 2870 requests access to medical records.
  • VA Form 21-4142 (Authorization to Disclose Information to the Department of Veterans Affairs): This document enables veterans to authorize the release of their medical records to the VA, akin to the DD 2870's purpose.
  • HIPAA Authorization Form: This form is used to grant permission for healthcare providers to share patient information. Like the DD 2870, it focuses on patient consent for record sharing.
  • DD Form 2005 (Privacy Act Statement): This form provides information on how personal data will be used and protected, paralleling the DD 2870's emphasis on privacy and consent.
  • SF 1176 (Authorization for Release of Medical Information): This document is used by healthcare providers to obtain permission to release medical information, similar to the DD 2870's function.
  • VA Form 21-22 (Appointment of Veterans Service Organization as Claimant's Representative): While primarily for appointing representatives, it also involves consent for sharing information, much like the DD 2870.
  • DD Form 2875 (System Authorization Access Request): This form is used to request access to information systems, reflecting the DD 2870's focus on authorization for accessing sensitive information.

Dos and Don'ts

When filling out the DD 2870 form, it is important to be careful and thorough. Here are some guidelines to help you avoid common mistakes and ensure your submission is complete.

  • Do read the instructions carefully before starting to fill out the form.
  • Do provide accurate and complete information to avoid delays.
  • Do double-check your entries for any spelling or numerical errors.
  • Do sign and date the form where required.
  • Don't leave any required fields blank; fill in all necessary information.
  • Don't submit the form without making copies for your records.

Following these tips can help ensure that your form is processed smoothly and efficiently.

Misconceptions

The DD 2870 form is often misunderstood. Here are ten common misconceptions about it, clarified for better understanding.

  1. It is only for military personnel.

    Many believe that the DD 2870 form is exclusively for active-duty military members. In reality, it can also be used by eligible family members and veterans seeking medical care.

  2. It is a complicated form.

    Some individuals think the DD 2870 is overly complex. However, the form is straightforward and designed for ease of use, with clear instructions provided.

  3. Submission is optional.

    While some may think submitting the DD 2870 is optional, it is actually a requirement for accessing certain medical benefits and services.

  4. It only applies to healthcare services.

    This form is often seen as limited to healthcare. In fact, it also pertains to other benefits, including dental and mental health services.

  5. Once submitted, it cannot be changed.

    Many believe that after submitting the DD 2870, no changes can be made. In truth, individuals can update their information as needed.

  6. It must be filled out in person.

    Some think that the form must be completed in person. However, it can be filled out online or submitted via mail, offering flexibility.

  7. There is a fee for submission.

    Another misconception is that there is a fee associated with submitting the DD 2870. The form is free to complete and submit.

  8. It is only valid for a short period.

    Some believe that the DD 2870 form has a limited validity period. In reality, it remains valid as long as the individual continues to qualify for benefits.

  9. It is not necessary for dependents.

    There is a common belief that dependents do not need to fill out the DD 2870. However, dependents must also complete the form to access their benefits.

  10. All information is shared publicly.

    Finally, some worry that submitting the DD 2870 exposes their personal information. In fact, the information is protected and used solely for benefit eligibility purposes.

Key takeaways

The DD 2870 form is an important document used primarily by military personnel and their families. Here are some key takeaways about filling out and using this form:

  • Purpose: The DD 2870 form is used to request a copy of a service member's medical records or other health information.
  • Eligibility: Only authorized individuals, such as the service member or their legal representative, can fill out this form.
  • Information Required: The form requires personal information, including the service member's full name, Social Security number, and details about the records being requested.
  • Submission: After completing the form, it must be submitted to the appropriate military medical facility or records office.
  • Processing Time: Be aware that it may take time to process the request, so it is advisable to submit the form well in advance of any deadlines.
  • Follow-Up: If you do not receive a response within a reasonable time frame, consider following up with the office where you submitted the form.