DDFORMS.ORG – DD Form 2005 – Privacy Act Statement – Health Care Records – The DD Form 2005 is a Privacy Act Statement for Health Care Records. The form is used to document an individual’s authorization for the release of their protected health information. The form must be completed and signed by the individual before their health care records can be released to any third party.
Download DD Form 2005 – Privacy Act Statement – Health Care Records
| Form Number | DD Form 2005 |
| Form Title | Privacy Act Statement – Health Care Records |
| Edition Date | 6/1/2016 |
| File Size | 36 KB |
What is a DD Form 2005?
A DD Form 2005 is a Privacy Act Statement that is used by military personnel to request access to their health care records. The form allows the individual to specify which records they would like to have released and to whom. The form must be signed and dated by the individual in order for the request to be processed.
Where Can I Find a DD Form 2005?
The DD Form 2005, also known as the Privacy Act Statement, is a form that must be completed by patients when they receive health care from the Department of Defense. The form ensures that the patient’s health information is protected and only shared with authorized personnel. The DD Form 2005 must be completed prior to receiving any health care services from the Department of Defense.
DD Form 2005 – Privacy Act Statement – Health Care Records
The Privacy Act of 1974 establishes rules for the collection, maintenance, use, and dissemination of personally identifiable information about individuals that is maintained in systems of records by federal agencies. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 also impose privacy requirements on covered entities, which include most healthcare, providers.
Federal law requires that when information about an individual is collected from that individual or from another person, the individual must be given a notice that includes:
- The authority for collecting the information;
- The purpose(s) for which it will be used;
- The routine uses that may be made of it;
- Any effect on the individual resulting from failure to supply all or part of the requested information; and
- The procedures whereby an individual may gain access to his/her own record or request amendment to it.
DD Form 2005 Example
