Your signature merely acknowledges that you have been advised of the foregoing. If requested, a copy of this form will be furnished to you.
Disclosure: voluntary.
Applies to: all requests for personal information made by MHS health care treatment personnel or for medical/dental treatment purposes.
Permanent record: this statement is intended to become a permanent part of your health care record.
PHI: any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164).
| Question | Answer |
|---|---|
| Form Name | DD Form 2005 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 8 |
| Avg. time to fill out | 2 min |
| Edition | JUN 2016 |
| Who signs | The patient or sponsor |
| Previous editions | Obsolete |
| Other names | DD 2005, DD Form 2005, DD2005, Form 2005, Privacy Act Statement, Health Care Records |
| Official source | DD Form 2005 (Rev JUN 2016), Department of Defense |
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