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HIPAA Forms

Request to Restrict Medical or Dental Information Form
The purpose of 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 (PHI). Guidelines regarding use of this form are contained in DoD 6025.18-R. This form may be updated after issuance of guidance from HHS and DoD regarding changes to the HIPAA Privacy Rule on restriction of disclosures.

Authorization for Disclosure of Medical or Dental Information Form
The purpose of this form is to provide the military treatment facility (MTF)/dental treatment facility (DTF)/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information (PHI). Guidelines regarding use of this form are contained in DoD 6025.18-R.

To file a HIPAA Privacy complaint, click here