Get Dd2870 Instructions

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.

Authorization for Disclosure of Medical or Dental Information (DD Form 2870) Your provider or contractor will use this form is to get your permission to share your protected health information to a third party for personal use; insurance; continued medical care; school; legal; retirement/separation; or other reasons.

Authorization for Disclosure of Medical or Dental Information (DD Form 2870) Use this form to authorize an individual to release information that is protected under the Federal Privacy Act. This form is not valid to designate a representative for the Appeals process.

Block 10: Expiration date of this authorization (the standard date is one year from the completion date of this form, although patient may choose any date of his/her choice).

To complete the DD Form 2870, please follow these instructions carefully: Block 1: Patient's name in this block. Block 2: Patient's date of birth in this block. Block 3: Patient's complete social security number in this block. Block 4: Indicate the date(s) of treatment you (the patient) wants released.

Patient information. Whose health records do you want? ... Clinic, hospital, care provider. Who has the information you want? ... Date of Services. Who has the information you want? ... Information to be released. ... Receiving party or destination of records. ... Purpose of release. ... Expiration date or duration of consent. ... Release instructions.

What is Form DD 2870? 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.