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Forms & Templates

On this page, you will find various forms that Military Health System uses to support its programs. Please scroll down the page or use the search box to find specific forms and templates.

Please note that files more than two years old may not be compliant with Section 508 of the Rehabilitation Act. If you need an accessible version of a particular file, please contact us and we will provide one for you.

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DD Form 2871: Request to Restrict Medical or Dental Information Form

Form/Template
12/1/2003

This form is to provide the patient with a means to request a restriction on the use and disclosure of his/her protected health information.

Recommended Content:

How HIPAA Protects You

DD Form 2870: Authorization for Disclosure of Medical or Dental Information Form

Form/Template
12/1/2003

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.

Recommended Content:

How HIPAA Protects You

Third Party Collections Program - Report on Program Results

Form/Template
6/1/2001

Use this form to submit your Third Party Collections Program reports.

Recommended Content:

Performance Measurements | Third Party Collection Program
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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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