SSN OF MEMBER OR SPONSOR
PRIVACY ACT STATEMENT - HEALTH CARE RECORDS
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.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION
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.
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.
THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU.
Sections 133, 1071-87, 3012, 5031 and 8012, title 10, United States Code and Executive Order 9397.
1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN)
2. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED
3. ROUTINE USES
DD FORM 2005, FEB 76
PREVIOUS EDITION IS OBSOLETE. Adobe Professional 7.0
SIGNATURE OF PATIENT OR SPONSOR DATE