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Medical Records

DD Form 2870 General Instructions

This form is used to allow an applicant to authorize the release of protected information to a person or entity of the beneficiary’s choosing.

This authorization will not apply to sensitive Protected Health Information (PHI), unless specifically authorized in Section 8 of Part I. Behavioral Health notes will not be included and must be requested separately.

Section I: Patient Data

  • Items 1 through 3: Complete the beneficiary/patient’s information.
  • Item 4: If the exact dates of testing are unknown, provide a range of approximate years.
  • Item 5: Select type of records to receive (Outpatient, Inpatient Admission / Procedure, or both).

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 name facility authorized with the release of information.
  • Items 6a-6d: Please enter name and contact information of person or facility to receive records.
  • Item 7: Select a Reason for Request.
  • Item 8: You may clarify information related to the date range and/or type of treatment/ exposure that you wish to be disclosed.
  • Item 9: The authorization will be effective the date the form is signed.
  • Item 10: The Authorization to Disclose is valid for one year (12 months) from the date you sign if you do not enter a date in the space provided.

Section III: Release Authorization

  • Sign and Date the authorization and indicate relationship to patient.
  • If a patient’s representative signs the authorization, please attach documentation of Representative’s authority (for example: Custody, Guardianship, Power of attorney, etc.).

Section IV: Medical Records

Staff Use Only. Leave blank.

Don't forget to keep your family's information up to date in DEERS!