Download the form
The scope here is Department-wide. DD Form 2871 — DD Form 2871, Request to Restrict Medical or Dental Information, December 2003 — exists to Request to Restrict Medical and Dental Information, and it applies across the services rather than inside one. That is what the DD prefix encodes: joint issue, single edition, every branch and defense agency working from identical paper.
Authority: not stated prescribes it, not stated maintains it. Those two names settle most disputes about why the form is being asked for. Local commands add timing on top; the requirement itself comes from above them.
Current edition is not stated, carried as not stated. Check that against any copy you already hold before doing anything else — Department-level revisions land everywhere simultaneously, so a stale file is stale across the whole Department.
Available: PDF, across 2 pages, roughly 28 fields.
All formats are free. One operational note: save the file locally and open it in a desktop reader. Browser-embedded viewers drop field properties and lose typed data without warning.
What the form asks for
- Section 1 - Patient Data. 1. Name (last, first, middle initial).
- 2. Date of birth (4 digit year, 2 digit month, 2 digit day).
- 3. Social Security/Identification Number.
- 4. Period of treatment: From - to (4 digit year, 2 digit month, 2 digit day).
- 5. Type of treatment. Press space bar to mark X in first box if outpatient, second box if inpatient, or third box if both.
- 6. Request/Restriction is directed to the TRICARE Health Plan or the following physician/facility: a. Name of physician, facility, or TRICARE health plan.
- 6.b. Address (street, city, state and zip code).
- 6.c. Telephone (include area code).
- 6.d. Fax (include area code).
- 7. Purpose of restriction (optional).
- 8. Requested dates of restriction. a. Start (4 digit year, 2 digit month, 2 digit day).
- 8.b. End date (4 digit year, 2 digit month, 2 digit day).
- 9. Specify medical information to be restricted (use back for additional space).
- Section 3 - Please read and sign below. 10. Signature of patient/guardian.
- 11. Relationship to patient (if applicable).
- 12. Date (4 digit year, 2 digit month, 2 digit day).
- 13. X first box if approved, second box if disapproved.
- Mark X if response is attached.
- 14. Signature of approving official.
- 15. Imprint of patient identification plate when available.
- Sponsor name.
- Sponsor rank.
- FMP/Sponsor SSN.
- Branch of service.
Edition check comes first, ahead of any entry. Compare the printed date to not stated and replace anything older. Department-level supersession is simultaneous across the services, so a superseded blank is not merely out of date locally; the office receiving it is already working from the new field structure whichever branch it belongs to.
Field-level questions go to the printed instructions, then to not stated, which is authoritative.
Submit to the office named in not stated or in local instruction; retain a duplicate before it leaves. Joint routing often sends a DD form across organizational boundaries, and tracing one afterward is not a same-day matter.
A number is a complete address in the DD series. Because the sequence is Department-level and not duplicated per service, there is nothing further to specify.
Where a procedure cites both a service form and a DD form, the two are unconnected. Service numbering answers to a service proponent, DD numbering to not stated or another Department office, and the two sequences were never aligned. Matching numbers mean nothing whatever.
Three drivers of revision: directive reissue, altered collection requirements, updated statutory notice text. No notification accompanies any of them, so download fresh and confirm not stated rather than reusing an archived file.
What is here is the blank form and a description of it. What is not here is legal guidance or any assurance about a particular filing — this page is not the issuing authority and does not speak for one. Those questions go to not stated, to your servicing administrative office, or to the authority identified in not stated.
Questions and answers
- What is DD Form 2871?
- DD Form 2871, Request to Restrict Medical or Dental Information, December 2003
- Which edition is current?
- Not stated by the publisher
- Who is responsible for this form?
- Not stated
- In which formats can it be downloaded?