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 …

May 24, 2016 · 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 …

PRINCIPAL PURPOSE(S): 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 …

horization form will result in the non-release of the protected health information. This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization.

Form DD2870 Instructions Authorization for Disclosure of Medical Information • Fields 1 – 13 Required by Correspondence to process request • Field 5 Type of treatment you are requesting (Outpatient, Inpatient, Both) • Field 6 Name of facility you are requesting records from

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 …

approved to send Protected Health Information. format. This will be the date you sign the DD Form 2870 in block 11. Block 10: Due to local policy, the DD Form 2870 is single-use only. As such, ensure the “Action. Completed” block is checked. Block 11: Ensure a signature of the requesting individual is provided. The signature can be either a wet.

DD Form 2870, Authorization for Disclosure of . dical or Dental Information, serves as the mechanism for beneficiaries to request copi. nly outpatient information, mark the block for “Outpatient.” If you mark both, a copy of your request wi. or civilian provider named by. L (paper) record if you wish to receive both your AHLTA reco.

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 OD Form 2870, Authorization for Disclosure of Medical or Dental Information, serves as the mechanism for beneficiaries to request copies of their medical record. All...