AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION PRIVACY ACT STATEMENT In accordance with the Privacy Act of 1974 (Public Law 93-579), the notice informs you of the purpose of the form.
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How do you fill out a DD Form 2870?
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.
What is standard form 2870?
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.
How long is a dd2870 good for?
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).
What is DD Form 2870 for?
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.
How to fill out DD Form 2870 for retirement?
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.
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