Get Dd Form 2870 Authorization For Disclosure Of Medical Or Dental Information December 2003

Filling out the DD Form 2870 online is a straightforward process that enables individuals to authorize the release of their medical or dental information. This guide provides step-by-step instructions to ensure users can easily navigate the form and complete it accurately.

Follow the steps to fill out the form successfully.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editing platform.
2. In Section I, enter the patient data. Provide your name (last, first, middle initial), date of birth in the format YYYYMMDD, and social security number. Then, specify the period of treatment by entering the start date and end date in the format YYYYMMDD.
3. Indicate the type of treatment by checking the appropriate box for outpatient, inpatient, or both.
4. In Section II, specify the entity to whom you are authorizing the release of your patient information by filling in the name of the physician, facility, or TRICARE health plan.
5. Complete the address section with the full street address, city, state, and ZIP code of the facility. Include the telephone and fax numbers as well.
6. Select the reason for the request by marking the relevant boxes, such as personal use, continued medical care, insurance, school, legal, or retirement/separation.
7. In the information to be released section, specify the details of the medical information you wish to disclose, such as school sports participation forms or immunization records.
8. Provide the authorization start date and the expiration date for this authorization in the format YYYYMMDD.
9. In Section III, read through the release authorization statements carefully and then sign the form in the designated area, indicating your relationship to the patient if applicable.
10. Enter the date of signing in the format YYYYMMDD to complete the authorization.
11. Once you have filled out the form, review all information for accuracy. You can then save changes, download a copy, print it out, or share it as needed.

Complete your documents online today to ensure a smooth process for your medical or dental information disclosure.