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When a student is authorized to drop below a full course of study, these dates\u2014 the date on which that authorization takes effect, and the date on which it expires\u2014 must be given.
To complete the DD Form 2870, please follow these instructions carefully: Block 1: Patient's name in this block. Block 2: Patient's date of birth in this block. Block 3: Patient's complete social security number in this block. Block 4: Indicate the date(s) of treatment you (the patient) wants released.
Block 10: Expiration date of this authorization (the standard date is one year from the completion date of this form, although patient may choose any date of his/her choice).
To complete the DD Form 2870, please follow these instructions carefully: Block 1: Patient's name in this block. Block 2: Patient's date of birth in this block. Block 3: Patient's complete social security number in this block. Block 4: Indicate the date(s) of treatment you (the patient) wants released.
Authorization for Disclosure of Medical or Dental Information (DD Form 2870) Your provider or contractor will use this form is to get your permission to share your protected health information to a third party for personal use; insurance; continued medical care; school; legal; retirement/separation; or other reasons.
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To complete the DD Form 2870, please follow these instructions carefully: Block 1: Patient's name in this block. Block 2: Patient's date of birth in this block. Block 3: Patient's complete social security number in this block. Block 4: Indicate the date(s) of treatment you (the patient) wants released.
When a student is authorized to drop below a full course of study, these dates\u2014 the date on which that authorization takes effect, and the date on which it expires\u2014 must be given.
Block 10: Expiration date of this authorization (the standard date is one year from the completion date of this form, although patient may choose any date of his/her choice).
PRINCIPAL PURPOSE(S): 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.
PRINCIPAL PURPOSE(S): 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 2870 instructions