Privacy Act of 1974 (As Amended) Public Law 93-579, as-2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, enter your personal data. Fill in your name, date of birth, and DOD number. Specify the period of treatment and type of treatment by checking the appropriate box.
3. Move to Section II. Authorize the release of your medical information by filling in the name of the facility or TRICARE Health Plan and providing their address, telephone number, and fax number.
4. Indicate the reason for requesting your medical information by checking all applicable boxes. If you wish to include sensitive information like mental health records or HIV/AIDS-related information, initial in the designated area.
5. Complete the authorization start and expiration dates in Section II.
6. In Section III, read through the release authorization statements carefully before signing. Ensure you understand your rights regarding revocation and disclosure.
7. Sign and date the form at the bottom of Section III. If applicable, indicate your relationship to the patient.

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