DD Form 2005 at a glance
What it is: DD Form 2005 is the Privacy Act Statement for Health Care Records.
Who signs: Sign in Box 5, Signature. Enter Social Security Number or DoD Identification Number of member or sponsor in Box 6.
A filled-in DD Form 2005 example: a patient signs for themselves with a DoD ID
How to fill out DD Form 2005, box by box
Boxes 5, 6 and 7, Signature, Social Security Number or DoD Identification Number and Date
Sign in Box 5, Signature. Enter Social Security Number or DoD Identification Number of member or sponsor in Box 6.
Enter the date in Box 7 as YYYYMMDD.
More rules for DD Form 2005
This form is not an authorization or consent to use or disclose your health information.
Box 2, Principal Purposes for Which Information Is Intended to Be Used: information may be collected from you to provide and document your medical care; determine your eligibility for benefits and entitlements; adjudicate claims; determine whether a third party is responsible for the cost of Military Health System (MHS) provided healthcare and recover that cost; evaluate your fitness for duty and medical concerns which may have resulted from an occupational or environmental hazard; evaluate the MHS and its programs; and perform administrative tasks related to MHS operations and personnel readiness.
Box 4, Whether Disclosure Is Mandatory or Voluntary and Effect on Individual of Not Providing Information: voluntary. If you choose not to provide the requested information, comprehensive health care services may not be possible, you may experience administrative delays, and you may be rejected for service or an assignment. However, care will not be denied. Your signature merely acknowledges that you have been advised of the Privacy Act Statement. If requested, a copy of this form will be furnished to you.
Sources
[1] DD Form 2005 (JUN 2016), Privacy Act Statement - Health Care Records, U.S. Department of Defense (the Official source link on this page).