Privacy

Authorization for Disclosure of Medical or Dental Information (DD Form 2870)

Your provider or contractor will use this form is to get your permission to share your protected health information to a third party for personal use; insurance; continued medical care; school; legal; retirement/separation; or other reasons. 

You do not have to sign this form as it is 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.

Active Duty Dental Program Request and Authorization for Disclosure of Health Information

This form should be completed to release PHI between spouses, for children 18 years and older or any other person not authorized to receive information without written authorization. This is necessary due to HIPAA Privacy Regulations.

TRICARE For Life Authorization to Disclose Information

By filling out this form, you are giving authorization to the TRICARE For Life contractor to release information protected under the Federal Privacy Act. This form is not valid to designate a representative for the Appeals process.

TRICARE Overseas Authorization to Disclose Information

By filling out this form, you are giving authorization to the TRICARE Overseas Program contractor to release information protected under the Federal Privacy Act. This form is not valid to designate a representative for the Appeals process.

Region-Specific Privacy Forms

Last Updated 5/1/2014