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DD Form 2871 — a Department of Defense document. Title of record: DD Form 2871, Request to Restrict Medical or Dental Information, December 2003. Stated purpose: Request to Restrict Medical and Dental Information. Edition date not stated; status not stated.
Governing directive: not stated. Responsible office: not stated. The DD designation signals joint scope — all military departments, combatant commands and defense agencies draw on a single edition of the document.
The form reaches military personnel across the services, civilian employees of the Department, and the personnel and records specialists who receive it.
Timing of submission is fixed by not stated and by the implementing guidance of the submitting organization. What follows describes the blank document, not agency procedure.
The download set covers PDF. Document length is 2 pages with about 28 entry fields.
Distribution centres on pdf. Two states exist: fillable, where field boxes accept keyboard input and retain it, and printable, a static blank produced for manual completion. Typed data reproduces cleanly across copies; handwritten data depends on the writer.
An xfdl file is provided as well. Xfdl is the IBM Lotus Forms format, historically standard across Defense form distribution, and it requires IBM Lotus Forms Viewer or an equivalent reader; ordinary pdf software will not open it.
Free download applies to every format listed. Any current pdf reader opens the pdf files, though field behaviour is most reliable in a full desktop reader rather than a browser preview.
What the form asks for
- Section 1 - Patient Data. 1. Name (last, first, middle initial).
- 2. Date of birth (4 digit year, 2 digit month, 2 digit day).
- 3. Social Security/Identification Number.
- 4. Period of treatment: From - to (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.
- 6. Request/Restriction is directed to the TRICARE Health Plan or the following physician/facility: a. 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. Purpose of restriction (optional).
- 8. Requested dates of restriction. a. Start (4 digit year, 2 digit month, 2 digit day).
- 8.b. End date (4 digit year, 2 digit month, 2 digit day).
- 9. Specify medical information to be restricted (use back for additional space).
- Section 3 - Please read and sign below. 10. Signature of patient/guardian.
- 11. Relationship to patient (if applicable).
- 12. Date (4 digit year, 2 digit month, 2 digit day).
- 13. X first box if approved, second box if disapproved.
- Mark X if response is attached.
- 14. Signature of approving official.
- 15. Imprint of patient identification plate when available.
- Sponsor name.
- Sponsor rank.
- FMP/Sponsor SSN.
- Branch of service.
The document is filled from the top down. Identification precedes substance, substance precedes certification. Fields lower on the page are commonly keyed to entries made above them.
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.
Guidance for specific entries sits on the form face and in not stated; the directive is authoritative where the two do not agree.
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.
Some procedures pair a DD form with a service form. The two numbering systems are separate — service forms answer to a service proponent, DD forms to not stated or another Department office — and a matching number in each system means nothing.
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 2871?
- DD Form 2871, Request to Restrict 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?