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

GENERAL INSTRUCTIONS

AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION

(DD FORM 2870)

This form is used to allow a TRICARE beneficiary to authorize Health Net Federal Services, LLC (Health Net) to

release protected information to a person or entity of the beneficiary’s choosing. Completion of this form is

voluntary. If this form is not completed in its entirety, your request will not be processed.

*This authorization will not apply to alcohol or substance abuse information

Sponsor Social Security Number (SSN): Please print the Sponsor’s 9-digit SSN on the TOP LEFT of the

form, above the word “Authorization”.

Section I: Patient Data

· Complete the beneficiary/patient’s information.

· Identify the date range and type of treatment information to be released.

Section II: Disclosure

This section identifies who may release information about the patient to an identified third party or authorized

representative.

· Item 6: Please enter “Health Net/TRICARE”.

· Items 6a-6d: Please complete the name and contact information of the authorized representative

(for example: the name and contact information of your spouse or parent).

· Item 7: Identify why the information will be disclosed.

· Item 8: You may clarify information related to the date range and/or type of treatment that you wish to

be disclosed.

· Item 9: The authorization will be effective the date the form is received.

· Item 10: If a calendar date is not provided, the authorization is incomplete and will be returned.

Section III: Release Authorization

· Sign and Date the authorization.

· If a patient’s representative signs the authorization, please attach documentation of the representative’s

authority (for example: Custody, Guardianship, Power of attorney, etc).

MAIL or FAX your completed form to:

TRICARE Correspondence PGBA, LLC P.O. Box 870141 Surfside Beach, SC 29587-9741

Fax: 1-888-225-3545

IMPORTANT:

This form grants permission for information disclosed by telephone or correspondence about

authorizations/referrals, claims, and enrollment only. It does NOT permit the person to see your claims on our

Web site, www.myTRICARE.com, or grant permission to make changes to your account. To grant permission for

someone to see your claims information on the Web site, you must do so within your account on

www.myTRICARE.com.

01/23/2014

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AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION

In accordance with the Privacy Act of 1974 (Public Law 93-579), the notice informs you of the purpose of the form and how

it will be used. Please read it carefully.

AUTHORITY: Public Law 104-191; E.O. 9397 (SSAN); DoD 6025.18-R.

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.

ROUTINE USE(S): To any third party or the individual upon authorization for the disclosure from the individual for: personal

use; insurance; continued medical care; school; legal; retirement/separation; or other reasons.

DISCLOSURE: Voluntary. Failure to sign the authorization 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 to disclose information from records of an alcohol or drug abuse treatment program. In addition, any use as

an authorization to use or disclose psychotherapy notes may not be combined with another authorization except one to use or

disclose psychotherapy notes.

PRIVACY ACT STATEMENT

SECTION I - PATIENT DATA

1. NAME (Last, First, Middle Initial) 2. DATE OF BIRTH (YYYYMMDD) 3. SOCIAL SECURITY NUMBER

4. PERIOD OF TREATMENT: FROM - TO (YYYYMMDD) 5. TYPE OF TREATMENT (X one)

OUTPATIENT INPATIENT BOTH

SECTION II - DISCLOSURE

6. I AUTHORIZE

a. NAME OF PHYSICIAN, FACILITY, OR TRICARE HEALTH PLAN b. ADDRESS (Street, City, State and ZIP Code)

c. TELEPHONE (Include Area Code)

d. FAX (Include Area Code)

10. AUTHORIZATION EXPIRATION9. AUTHORIZATION START DATE (YYYYMMDD)

DATE (YYYYMMDD)

8. INFORMATION TO BE RELEASED

SECTION III - RELEASE AUTHORIZATION

I understand that:

a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility

where my medical records are kept or to the TMA Privacy Officer if this is an authorization for information possessed by the

TRICARE Health Plan rather than an MTF or DTF. I am aware that if I later revoke this authorization, the person(s) I herein

name will have used and/or disclosed my protected information on the basis of this authorization.

b. If I authorize my protected health information to be disclosed to someone who is not required to comply with federal

privacy protection regulations, then such information may be re-disclosed and would no longer be protected.

c. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance

with the requirements of the federal privacy protection regulations found in the Privacy Act and 45 CFR 164.524.

d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment

by the TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to

obtain this authorization.

I request and authorize the named provider/treatment facility/TRICARE Health Plan to release the information described above

to the named individual/organization indicated.

11. SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE 12. RELATIONSHIP TO PATIENT

(If applicable)

13. DATE (YYYYMMDD)

SECTION IV - FOR STAFF USE ONLY (To be completed only upon receipt of written revocation)

14. X IF APPLICABLE:

AUTHORIZATION

REVOKED

15. REVOCATION COMPLETED BY

17. IMPRINT OF PATIENT IDENTIFICATION PLATE WHEN AVAILABLE

SPONSOR NAME:

FMP/SPONSOR SSN:

SPONSOR RANK:

BRANCH OF SERVICE:

PHONE NUMBER:

DD FORM 2870, DEC 2003

16. DATE (YYYYMMDD)

ACTION COMPLETED

7. REASON FOR REQUEST/USE OF MEDICAL INFORMATION (X as applicable)

PERSONAL USE

INSURANCE

CONTINUED MEDICAL CARE

RETIREMENT/SEPARATION

SCHOOL

LEGAL

OTHER (Specify)

(Name of Facility/TRICARE Health Plan)

TO RELEASE MY PATIENT INFORMATION TO:

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