DD Form 2870 Authorization for Disclosure of Medical or Dental Information

DD Form 2870 Instructions

1. Section I contains the ID information of the person requesting disclosure. This section also includes the period and type of treatment being revealed. To reveal all medical records, use the day entering the military as a starting point.
2. State the facility or TRICARE Health Plan authorized to disclose patient data and the organization to receive it in Section II. Check the reason for the release and briefly specify the information to be disclosed. Finally, state the authorization start and expiration dates.
3. Section III requires the patient's signature and the date. If they are unable to sign, the legal representative can do this. In this case, the form must be submitted with a document confirming the representatives' authority.
4. Section IV should be left blank. It is filled by the staff in case of revocation.

DD 2870 Related Forms:

• TRICARE for Life Authorization to Disclose Information gives the permission to your TRICARE for Life contractor to disclose the protected health information (PHI);
• TRICARE Overseas Authorization to Disclose Information provides the authority to the TRICARE Overseas Program contractor to release your protected health information;
• Active Duty Dental Program Request and Authorization for Disclosure of Health Information authorizes the disclosure of health data between spouses, for children 18 years and older or other individuals not allowed to receive PHI without written permission.