Army Forms Archive

DD Form 2870 — DD Form 2870, Authorization for Disclosure of Medical or Dental Information, December 2003

Authorization for Disclosure of Medical or Dental Information

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Department of Defense form 2870. Official designation: DD Form 2870, Authorization for Disclosure of Medical or Dental Information, December 2003. Purpose: Authorization for Disclosure of Medical or Dental Information. Current edition not stated, status not stated.

Issued under not stated, with not stated as proponent. A DD number marks a Department-wide instrument: the same blank form serves every military department and the defense agencies, rather than one service alone.

Users include uniformed members of any branch, DoD civilian employees, contractor personnel where authorized, and the administrative staff who process the completed record.

When the form is filed is a matter of not stated and local instruction. The description here covers the document itself and how to obtain a copy.

Formats offered: PDF. Length: 1 pages. Fillable field count: roughly 36.

The pdf is the primary distribution format. A fillable pdf accepts typed entries in defined field boxes and stores them in the file; a printable pdf is a flat image of the blank, meant for pen entry after printing. The distinction matters for legibility and for records that pass between offices.

What the form asks for

  • Section 1 - Patient Data. 1. Name (last, first, middle initial).
  • 3. Social Security Number. Do not include dashes.
  • 4. Period of treatment: From - to (4 digit year, 2 digit month, 2 digit day).
  • 2. Date of birth (4 digit year, 2 digit month, 2 digit day).
  • 5. Type of treatment. Press space bar to mark X in first box if outpatient, second box if inpatient, or third box if both.
  • Section 2 - Disclosure. 6. I authorize: (name of facility/TRICARE health plan):
  • 6.a. Release my patient information to: name of physician, facility, or TRICARE health plan.
  • 6.b. Address (street, city, state and zip code).
  • 6.c. Telephone (include area code).
  • 6.d. Fax (include area code).
  • 7. Reason for request/use of medical information (X as applicable). Mark X if personal use.
  • Mark X if insurance.
  • Mark X if continued medical care.
  • Mark X if retirement/separation.
  • Mark X if school.
  • Mark X if legal.
  • Mark X if other.
  • Specify other reason.
  • 8. Information to be released.
  • 9. Authorization start date (4 digit year, 2 digit month, 2 digit day).
  • 10. Authorization expiration. Mark X if date.
  • Specify expiration date (4 digit year, 2 digit month, 2 digit day).
  • Mark X if action completed.
  • Section 4 - For staff use only (to be completed only upon receipt of written revocation). 14. Mark X if authorization revoked.

Order of completion: identification block first, substantive entries second, certification and signature last. The blank is laid out in that sequence and the sequence is not arbitrary — later entries often depend on data established in the header.

Verify the edition date against not stated before entry. Department-level revisions replace the blank across every service simultaneously, so an old copy in a desk drawer may no longer correspond to current field numbering.

Instructions printed on the form or in not stated govern individual field entries. Where the two differ, the governing publication controls.

After completion, the copy goes to the office designated by not stated or by local procedure. Retention of a personal copy is ordinary practice and costs nothing.

Associated forms are traced by number within the series. Because the DD sequence is common to all military departments, no service qualifier is needed to identify a referenced form.

Where a DA form is cited alongside a DD form, the two belong to different systems: DA numbering is Army-specific and administered by an Army proponent, while DD numbering is Defense-wide under not stated or an equivalent Department office. Numbers do not translate between the systems.

Editions change because the underlying directive changes, because collection requirements are revised, or because Privacy Act language is updated. Checking the edition date at the point of download is the practical response.

The material here is descriptive. Nothing on the page constitutes legal or procedural advice, and no statement here determines whether a submitted form will be accepted. Such questions go to not stated, a servicing administrative office, or the authority identified in not stated.

Questions and answers

What is DD Form 2870?
DD Form 2870, Authorization for Disclosure of Medical or Dental Information, December 2003
Which edition is current?
Not stated by the publisher
Who is responsible for this form?
Not stated
In which formats can it be downloaded?
PDF

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