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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.
DD Form 2870 collects patient data and a patient’s, or their parent’s or legal representative’s, authorization for a military treatment facility or dental treatment facility or DoD health plan to use or disclose an individual’s protected health information.
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.
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.
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.
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.
The attached DD Form 2870, Authorization for Disclosure of Medical or Dental Information, authorizes Fox Army Health Center (FACH) to release medical information to specific individuals other than the patient for purposes other than treatment, payment or healthcare operations.
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.
The attached DD Form 2870, Authorization for Disclosure of Medical or Dental Information, authorizes Reynolds Army Health Clinic (RACH)to release medical information to specific individuals or yourself.
INSTRUCTIONS FOR FILLING OUT DD FORM 2870 (Authorization for Disclosure of Medical or Dental Information) 1. Patient Name 2. Patient Date of Birth 3. Patient SSN 4. From and To dates to identify the time period of the services received for which you are requesting the records.