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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...
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.
DD Form 877-1 is the only request form which NPRC will accept from military facilities for retired medical treatment records. Read the information below before completing the front of this form. 1. Please check to make sure that records from recent years have been retired to NPRC before preparing this form. Most inactive records are
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 facility or DoD health plan to use or disclose an individual’s protected health information.
Find and download official DA forms from the Army Publishing Directorate website.
Provide Release of information form DD FORM 2870. DoD Identification card. Complete all highlighted section on DD FORM 2870. Provide current telephone number and address. To Request records other than for your-self and the patient is over 18 years of age, the following documents are required: DoD identification card.
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