DD Form 2870 — Authorization for Disclosure of Medical or Dental Information

Privacy Act Statement

Authority: Public Law 104-191 (HIPAA of 1996); 10 U.S.C. Chapter 55; DoDM 6025.18; E.O. 9397 (SSN). Purpose: Collects patient data and your authorization for a military/dental treatment facility or DoD health plan to use or disclose your protected health information. Disclosure: Voluntary — if you don't provide it, your information will not be released. This form does not authorize disclosure of substance-abuse information/treatment or psychotherapy notes.

I Patient Data

1. Name * (Last, First, Middle Initial)

Name is required.

2. Date of Birth *

Date of birth is required.

3. SSN or DoD ID Number * (DoD ID preferred)

SSN or DoD ID is required.

4. Period of Treatment (From – To)

5. Type of Treatment

Both

Inpatient

Outpatient

Sponsor Name

Sponsor Rank

FMP / Sponsor SSN

Branch of Service

Phone Number

II Disclosure

6. I authorize * (Name of Facility / TRICARE Health Plan) — to release my patient information to:

Releasing facility is required.

6a. Name of person or organization to receive my medical information *

Recipient is required.

6b. Address (Street, City, State, ZIP)

6c. Telephone (Include Area Code)

6d. Fax (Include Area Code)

7. Reason for request / use of medical information * (select all that apply)

Select at least one reason.

8. Information to be released *

Please describe the information to be released.

9. Authorization Start Date

10. Authorization Expiration Date — set 1 year

III Release Authorization

I understand that:

a. I have the right to revoke this authorization at any time, in writing, provided to the facility where my records are kept or the TMA Privacy Officer. Information already used or disclosed on this authorization cannot be retrieved.

b. If I authorize disclosure to someone not required to comply with federal privacy regulations, the information may be re-disclosed and would no longer be protected.

c. I have a right to inspect and receive a copy of my protected health information to be used or disclosed (Privacy Act and 45 CFR 164.524).

d. The Military Health System may not condition treatment, payment, enrollment, or eligibility for TRICARE benefits on whether I sign 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, and I confirm I understand my rights above. *

11. Signature of Patient / Parent / Legal Representative *

Sign with mouse or finger — time-stamped & bound to this form.

A signature is required to authorize this release.

12. Relationship to Patient (if not self)

13. Date

IV For Staff Use Only — complete only upon receipt of written revocation

14. Revocation

Authorization Revoked

15. Revocation Completed By

16. Date

Digitizes the official DD Form 2870 for the CloudCare PHA system. All data is marked CUI // PRVCY when filled and encrypted in transit and at rest.

Authorization submitted