DD 2870: Authorization for Disclosure of Medical or Dental Information
The NOV 2023 HIPAA release: who releases what, to whom, why, and for how long, plus the revocation block.
Every block on the DD Form 2870
Laid out block for block like the official AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION (NOV 2023 edition), with the instruction for each block. Name, rank, and unit prefill from your service profile.
Section i - patient data
- 1Name (Last, First, Middle Initial)
- 2Date of Birth (YYYYMMDD)
- 3Social Security Number
Write it on the signed form rather than storing it in this draft.
- 4Period of Treatment: From - To (YYYYMMDD)
- 5Type of Treatment (X one)
Section ii - disclosure
- 6I authorize (Name of Facility/TRICARE Health Plan) to release my patient information to:
- 6aName of Person or Organization to Receive My Medical Information
- 6bAddress (Street, City, State and ZIP Code)
- 6cTelephone (Include Area Code)
- 6dFax (Include Area Code)
- 7Reason for Request/Use of Medical Information (X as applicable)
- Other (Specify)
- 8Information to Be Released
Be specific: record types, clinics, and dates.
- 9Authorization Start Date (YYYYMMDD)
- 10Authorization Expiration: Date (YYYYMMDD) or Action Completed
Mark either a date or "Action completed" (ends once the release is done).
Section iii - release authorization
- 11Signature of Patient/Parent/Legal Representative
By signing you acknowledge: you can revoke in writing; records sent to a non-covered recipient may be re-disclosed; you can inspect and copy your records; and treatment or TRICARE benefits can't be conditioned on signing.
- 12Relationship to Patient (If applicable)
- 13Date (YYYYMMDD)
Section iv - for staff use only (To be completed only upon receipt of written revocation)
- 14X if applicable: Authorization Revoked
Staff use only, after a written revocation is received.
- 15Revocation Completed By
- 16Date (YYYYMMDD)
- 17Imprint of Patient Identification Plate When Available
- Sponsor Name / Sponsor Rank / FMP/Sponsor SSN / Branch of Service / Phone Number
For family members: the sponsor's details, printed beside the imprint block.
How to fill out the DD Form 2870
Your written permission for a military hospital, dental clinic, or TRICARE to send your health records to someone else: a civilian doctor, an insurer, a school, a lawyer, or yourself. When: Before a civilian specialist appointment, a VA claim or separation physical that needs records sent, a life insurance application, a school or sports physical, or a legal matter.
Step by step
- Section I: your name, date of birth, SSN, the treatment period, and inpatient/outpatient.
- Block 6: name the facility or TRICARE plan that holds the records, then who receives them, with address, phone, and fax.
- Block 7: mark why. Block 8: describe exactly what to release.
- Blocks 9–10: when the authorization starts, and when it ends (a date, or when the action is completed).
- Sign and date. A parent or legal representative signs for a minor or incapacitated patient and states the relationship.
What a strong one looks like
- Ask only for what's needed: "Orthopedic clinic notes, MRI reports, and operative report, 20250101–20260601" beats "entire record", and it's processed faster.
- Use "Action completed" for one-time releases so the authorization doesn't stay open.
- You can revoke it any time in writing to the facility holding your records.
Common mistakes
- Using this form for substance abuse treatment records or psychotherapy notes. Those need a separate authorization.
- Leaving the recipient's fax or address blank. The records office can't send it.
- Not signing, or letting a spouse sign for an adult patient without legal authority.