Structure
Misconceptions
The DD 2870 form is often misunderstood. Here are five common misconceptions about this form:
- It is only for military personnel. Many believe that only active duty members need to fill out the DD 2870. In reality, this form is also applicable to veterans and their family members seeking benefits.
- Submission is optional. Some think that completing the DD 2870 is not necessary. However, submitting this form is crucial for processing claims related to health care and benefits.
- It can be filled out without assistance. While the form is straightforward, many people assume they can complete it without help. In fact, seeking guidance can ensure that all necessary information is accurately provided.
- It only needs to be submitted once. There is a belief that the DD 2870 is a one-time requirement. In truth, individuals may need to resubmit the form if their circumstances change or if they are applying for different benefits.
- It does not require supporting documents. Some individuals think the form can be submitted alone. However, additional documentation may be necessary to support the claims made on the DD 2870.
Understanding these misconceptions can help ensure that the DD 2870 form is completed correctly and efficiently.
Detailed Steps for Filling Out DD 2870
Once you have obtained the DD 2870 form, it is important to complete it accurately to ensure that your request is processed efficiently. Follow the steps below to fill out the form correctly.
- Begin by entering your personal information in the designated fields. This includes your full name, Social Security number, and contact information.
- Provide your military affiliation. Indicate whether you are active duty, a veteran, or a dependent.
- Complete the section regarding the specific information you are requesting. Be clear and concise in your description.
- Sign and date the form at the bottom. Ensure that your signature matches the name provided at the top of the form.
- Review the entire form for accuracy. Check all entries for spelling and completeness.
- Submit the completed form as instructed. Follow the guidelines for mailing or electronic submission as applicable.
After submitting the DD 2870 form, you may need to wait for a response regarding your request. Keep an eye on your contact information for any updates or additional requirements that may arise.
Document 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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Dos and Don'ts
When filling out the DD 2870 form, it’s important to follow certain guidelines to ensure accuracy and completeness. Here’s a helpful list of things to do and avoid.
- Do read the instructions carefully before starting.
- Do fill out all required fields completely.
- Do use black or blue ink for clarity.
- Do double-check your personal information for accuracy.
- Do sign and date the form where indicated.
- Don't leave any mandatory sections blank.
- Don't use abbreviations unless specified in the instructions.
- Don't submit the form without reviewing it for errors.
- Don't forget to keep a copy for your records.
- Don't rush through the process; take your time to ensure everything is correct.
Key takeaways
The DD 2870 form is an important document used primarily by military personnel and their families. Understanding how to fill it out and use it effectively is crucial for ensuring that benefits and services are accessed smoothly. Here are some key takeaways regarding the form:
- Purpose of the Form: The DD 2870 form is used to request access to medical records and other health-related information.
- Eligibility: Ensure that you are eligible to request the information, as this form is typically for service members, veterans, and their dependents.
- Completing the Form: Fill out all required fields accurately. Missing information can delay processing and access to records.
- Signature Requirement: The form must be signed by the individual requesting the records. This confirms your consent for the release of information.
- Submission Process: After completing the form, submit it to the appropriate medical facility or records office as specified in the instructions.
- Follow-Up: If you do not receive a response within the expected timeframe, it is advisable to follow up to ensure your request is being processed.
By keeping these points in mind, individuals can navigate the process of using the DD 2870 form more effectively. Accessing medical records is an important step in managing health care needs, and proper completion of this form plays a vital role in that process.
Similar forms
The DD 214 form serves as a certificate of release or discharge from active duty in the U.S. Armed Forces. Like the DD 2870, which is used for requesting medical records, the DD 214 provides essential information about a service member’s military history. Both documents require accurate personal information and may be necessary for veterans to access benefits or services. The DD 214, however, focuses on the service member's discharge status, which can impact eligibility for various programs, while the DD 2870 is specifically tailored for health-related requests.
The SF 180 form, or Request Pertaining to Military Records, shares similarities with the DD 2870 in that it is also used to request access to military records. This form allows veterans and their families to obtain copies of their service records, including medical documentation. Both forms facilitate the retrieval of important information, but the SF 180 is broader in scope, encompassing a wider range of military records beyond just medical history. The SF 180 is often used for claims or benefits, similar to the purpose of the DD 2870.
The VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, is another document that aligns with the DD 2870 in terms of serving veterans. While the DD 2870 requests medical records, the VA Form 21-526EZ is used to apply for disability benefits based on those records. Both forms are critical in the claims process for veterans, as they help establish the necessary documentation to support claims. The focus of the VA Form 21-526EZ is on compensation, while the DD 2870 is about obtaining the medical evidence needed to substantiate such claims.
The HIPAA Authorization Form also bears resemblance to the DD 2870, as it is utilized to grant permission for the release of an individual's medical records. Both documents prioritize the individual's rights regarding their health information. The DD 2870 is specific to military medical records, whereas the HIPAA Authorization Form applies to all healthcare providers and settings. Each form ensures that the individual's consent is obtained before any medical information is shared, reinforcing the importance of privacy and control over personal health data.
Documents used along the form
The DD 2870 form is an essential document used in the military context, particularly for authorizing the release of health information. However, there are several other forms and documents that often accompany it, facilitating various processes related to health care and benefits. Below is a list of these documents, each serving a specific purpose.
- DD Form 214: This form is issued upon a service member's retirement, discharge, or release from active duty. It provides a summary of the service member's military history and is often required for accessing benefits.
- SF 180: The Standard Form 180 is used to request military records. Veterans and their next of kin can use this form to obtain information about service, including discharge status and awards.
- VA Form 21-526EZ: This is the application for disability compensation and related compensation benefits. Veterans seeking compensation for service-related injuries or conditions must submit this form.
- DD Form 2875: This form is a system authorization access request. It is used to request access to various Department of Defense systems, which may include health information systems.
- VA Form 10-10EZ: The application for health benefits from the Department of Veterans Affairs, this form is essential for veterans seeking health care services.
- DD Form 149: This form is used to apply for a correction of military records. Service members or veterans may use it to request changes to their discharge status or other personal information.
- SF 50: The Standard Form 50 is used to document personnel actions, such as appointments, promotions, and separations within federal employment. It may be relevant for veterans transitioning to civilian roles.
- VA Form 21-4138: Known as the Statement in Support of Claim, this form allows veterans to provide additional information or evidence to support their claims for benefits.
- DD Form 2766: This form is a record of the service member's medical history and is often used to facilitate care during transitions between military and civilian health systems.
Understanding these forms and their purposes can significantly aid service members and veterans in navigating the complexities of health care and benefits. Each document plays a crucial role in ensuring that individuals receive the support and services they deserve.