Dd Form 2005 PDF Details

The DD Form, integral to the administration of health care within the military and associated personnel, serves a multifaceted purpose aimed at protecting privacy while ensuring efficient care. At its core, the document adheres to the outlines established by the Privacy Act of 1974, emphasizing the non-consensual nature of this form relating to the release or utilization of health care information. Information collected under this form, particularly sensitive data such as the Social Security Number (SSN), is meticulously outlined to serve primary functions such as facilitating, documenting, and planning health care. This form is broad in its scope, covering the collection authority with its roots in specific sections of title 10, United States Code, and backed by executive orders. It addresses the varied uses of the gathered data, extending beyond health care provision to encompass roles in communicable disease control, statistical analyses, and even in assessing suitability for service. Moreover, the disclosure of information, while mandatory for military personnel due to the implications on future rights and benefits, remains voluntary for other beneficiaries, underlining the commitment to comprehensive care irrespective of data provision. This careful balance reflects the aim of the DD Form to maintain individuals' privacy while facilitating the broad spectrum of health care services and administrative necessities inherent to military and associated civilian personnel.

QuestionAnswer
Form NameDd Form 2005
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescommunicable, 2005, inclusive, enactment

Form Preview Example

PRIVACY ACT STATEMENT - HEALTH CARE RECORDS

THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU.

1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN)

Sections 133, 1071-87, 3012, 5031 and 8012, title 10, United States Code and Executive Order 9397.

2. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED

This form provides you the advice required by The Privacy Act of 1974. The personal information will facilitate and document your health care. The Social Security Number (SSN) of member or sponsor is required to identify and retrieve health care records.

3. ROUTINE USES

The primary use of this information is to provide, plan and coordinate health care. As prior to enactment of the Privacy Act, other possible uses are to: Aid in preventive health and communicable disease control programs and report medical conditions required by law to federal, state and local agencies; compile statistical data; conduct research; teach; determine suitability of persons for service or assignments; adjudi- cate claims and determine benefits; other lawful purposes, including law enforcement and litigation; con- duct authorized investigations; evaluate care rendered; determine professional certification and hospital accreditation; provide physical qualifications of patients to agencies of federal, state, or local govern- ment upon request in the pursuit of their official duties.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION

In the case of military personnel, the requested information is mandatory because of the need to document all active duty medical incidents in view of future rights and benefits. In the case of all other personnel/ beneficiaries, the requested information is voluntary. If the requested information is not furnished, compre- hensive health care may not be possible, but CARE WILL NOT BE DENIED.

This all inclusive Privacy Act Statement will apply to all requests for personal information made by health care treatment personnel or for medical/dental treatment purposes and will become a permanent part of your health care record.

Your signature merely acknowledges that you have been advised of the foregoing. If requested, a copy of this form will be furnished to you.

SIGNATURE OF PATIENT OR SPONSOR

SSN OF MEMBER OR SPONSOR

DATE

DD FORM 2005, FEB 76

PREVIOUS EDITION IS OBSOLETE.

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