Get Dd Form 2870, Dec 2003

Filling out the DD FORM 2870, DEC 2003 is essential for authorizing the disclosure of medical or dental information. This guide provides step-by-step instructions to help users navigate the form with ease.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in your browser.
2. In Section I, enter your personal information: Fill in your last name, first name, and middle initial. Input your date of birth in the format YYYYMMDD, and provide your social security number. Specify the period of treatment by entering the start and end dates in the format YYYYMMDD. Indicate the type of treatment by selecting either outpatient or inpatient.
3. In Section II, specify the facility or physician authorized to release your patient information. Enter the name of the facility or TRICARE health plan, followed by the facility's address, including street, city, state, and ZIP code. Include telephone and fax numbers as requested.
4. Indicate the reason for the request by selecting applicable options, such as personal use, continued medical care, or other reasons. In the provided field, specify any other relevant details.
5. Clearly state what information is to be released in Section II. Include any specifics if applicable.
6. Enter the authorization start and expiration dates in the format YYYYMMDD to determine the active period of your authorization.
7. Read the Release Authorization section carefully. Acknowledge that you have the right to revoke this authorization at any time by signing the document at the designated area.
8. Finally, complete the bottom section by signing as the patient, parent, or legal representative. Provide the relationship to the patient and the date of signing in the specified fields.
9. Once completed, save your changes, download a copy, print it for your records, or share it as necessary.

Start filling out your DD FORM 2870 online today to ensure the proper management of your medical information.