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.