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9397 ISSANI; DoD 6026.1B-Fl. PRINCIPAL PURPOSEISI: This form is to provide the Military Treatment Facility/Dental Treatment FaciIityITRICAFIE Health Plan.

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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.

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).

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.

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.

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.

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.

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.

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