AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION
PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974 (Public Law 93-579), the notice informs you of the purpose of the form and how
it will be used. Please read it carefully.
AUTHORITY: Public Law 104-191; EQ. 9397 (SSAN); DoD 6025.18-fl.
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 individuals protected health information.
ROUTINE USE(S): To any third party or the individual upon authorization for the disclosure from the individual for: personal
use; insurance; continued medical care; school; legal; retirement/separation; or other reasons.
DISCLOSURE: Voluntary. Failure to sign the authorization form will result in the non-release of the protected health
This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or
for authorization to disclose information from records of an alcohol or drug abuse treatment program.
In addition, any use as
an authorization to use or disclose psychotherapy notes may not be combined with another authorization except one to use or
disclose psychotherapy notes.
1. NAME (Last, First, Middle Initial)
2. DATE OF BIRTH (YYYYMMDD) 3. SOCIAL SECURITY NUMBER
4. PERIOD OF TREATMENT: FROM - TO (YYYYMMDD)
5. TYPE OF TREATMENT (X one)
SECTION II - DISCLOSURE
TO RELEASE MY PATIENT INFORMATION TO:
(Name of Facility/TRICARE Health Plan)
a. NAME OF PHYSICIAN, FACILITY. OR TRICARE HEALTH PLAN
b. ADDRESS (Street, City, State and ZIP Code)
c. TELEPHONE (Include Area Code)
d. FAX (Include Area Code)
7. REASON FOR REQUEST/USE OF MEDICAL INFORMATION (X as applicable)
~ PERSONAL USE
CONTINUED MEDICAL CARE
INFORMATION TO BE RELEASED
9. AUTHORIZATION START DATE (YYYYMMDD)
10. AUTHORIZATION EXPI