DD Form 2871. Request to Restrict Medical and Dental Information

DD Form 2871, known as the "Request to Restrict Medical and Dental Information," is a document utilized within the United States Department of Defense (DoD). The form is employed for the purpose of enabling patients to request the restriction of their protected health information within the military medical and dental treatment facilities. This request is made under the authority of the Privacy Act of 1974 and adheres to the regulations specified in Public Law 104-191, E.O. 9397 (SSAN), and DoD 6025.18-R.

Purpose:

The primary purpose of DD Form 2871 is to empower patients to exercise control over the use and disclosure of their protected health information within the DoD's medical and dental treatment facilities. Patients may request the restriction of certain medical or dental data, and this form serves as a formal request for such restrictions. The form also ensures that patients understand the circumstances under which their restricted health information can still be accessed.

Usage Case:

This form is employed in the following context:

• Patient-Initiated Restriction Request: Patients within the military medical and dental treatment facilities who wish to restrict specific aspects of their health information can use DD Form 2871 to make an official request. This request might be based on privacy concerns, personal preferences, or other valid reasons.

Structure:

DD Form 2871 is a comprehensive document with distinct sections, each serving a specific purpose:

Section I - Patient Data:

1. Name: The patient's full name (Last, First, Middle Initial).
2. Date of Birth: The patient's date of birth in YYYYMMDD format.
3. Social Security/Identification Number: The patient's Social Security or identification number.
4. Period of Treatment: Indicates the time frame for the requested restriction, specifying the start and end dates (in YYYYMMDD format).
5. Type of Treatment: The patient selects the appropriate treatment type (OUTPATIENT, INPATIENT, or BOTH).

Section II - Restrictions: 6. Request Directed to: The patient identifies whether the restriction request is directed to the TRICARE Health Plan or a specific physician/facility.

• a. Name of Physician, Facility, or TRICARE Health Plan
• b. Address: The complete address, including street, city, state, and ZIP code.
• c. Telephone: The contact phone number, including the area code.
• d. Fax: The fax number, including the area code.

8. Requested Dates of Restriction: Specifies the start and end dates for the requested restriction in YYYYMMDD format.
9. Purpose of Restriction (Optional): The patient may provide additional context for the requested restriction.

Section III - Patient Acknowledgment and Signature: The patient acknowledges the implications of the requested restriction and signs the form. The section includes a series of statements regarding the scope and limitations of the restriction, including the termination conditions.

Section IV - For Provider/Facility Use Only: This section is intended for use by the medical or dental facility or provider to indicate whether the request has been approved or disapproved. The provider may attach additional information as needed.

DD Form 2871 contains both a Privacy Act Statement and a clear explanation of the form's purpose, ensuring that patients understand the implications of their request. It allows patients to retain some control over their health information while ensuring that necessary access is maintained in critical situations.