Privacy

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

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

You don't have to sign this form. It's voluntary. If you don't sign the form, your personal health information won't be released.

We won't use this form to authorize disclosure of alcohol or drug abuse patient information from medical records or disclosure of information from records of an alcohol or drug abuse treatment program.

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

Complete this form 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're giving authorization to the TRICARE For Life contractor to release information protected under the Federal Privacy Act. This form isn't valid to designate a representative for the appeals process.

TRICARE Overseas Authorization to Disclose Information

By filling out this form, you're giving authorization to the TRICARE Overseas contractor to release information protected under the Federal Privacy Act. This form isn't valid to designate a representative for the appeals process.

Region-Specific Privacy Forms

• East Region
• West Region
• Overseas